M. J. Hurley3, J. B. Holcomb2,3 2Memorial Hermann Hospital,Department Of Surgery,Houston, TX, USA 3University Of Texas Health Science Center At Houston,Center For Translational Injury Research,Houston, TX, USA
Introduction: Uncontrolled intra-abdominal hemorrhage after injury is associated with increased mortality. Current treatment consists of rapid transport to a trauma center and emergent laparotomy. Three potential prehospital hemorrhage control interventions that could lead to improved outcomes are resuscitative endovascular balloon occlusion of the aorta (REBOA), self-expanding foam and the abdominal junctional tourniquet (AJT). The purpose of this retrospective study was to assess the number of patients who had intra-abdominal injury and received a laparotomy that could have potentially benefited from one of these three new interventions.
Methods: This retrospective study included patients who received an emergent trauma laparotomy between 1/1/2013 to 1/1/2015 at an urban Level 1 trauma center. We reviewed all the injuries found at laparotomy and based on the specific indications for each device determined if the patients would have been potentially helped or hurt by each of the three interventions. For instance, the AJT only controls bleeding from injuries below the aortic bifurcation (located below the umbilicus), while the foam is contraindicated in patients with large abdominal wall defects or diaphragm injuries. McNemar’s test was used with Bonferonni correction for statistical analysis (α=0.017).
Results: 402 patients met the inclusion criteria. REBOA was potentially beneficial for 384, (96%) of patients, foam was potentially beneficial for 351, (87%), while the AJT was potentially beneficial for only 35, (9%). There was no significant difference between REBOA and foam (p=0.022), while there was a difference between REBOA or foam and AJT (p<0.001). There were 170 (42%) patients with penetrating injuries, while only 9 (5%) patients with penetrating injuries would have been potentially helped by the AJT. 33 patients had cutaneous wounds located in the right lower quadrant (RLQ), while 45 patients had cutaneous wounds located in the left lower quadrant (LLQ). Diaphragm injuries occurred in 58 (14%) of patients, with REBOA potentially of benefit in 55 of those patients, while foam would have potentially helped only 36.
Conclusion: REBOA and foam both would potentially benefit the largest number of patients, (≥ 87%) who had intra-abdominal injury and laparotomy. AJT was found to be helpful in only 9% of patients in need of prehospital intervention for hemorrhage. These results suggest that the AJT should not be used for prehospital hemorrhage control unless it is absolutely sure that all injuries causing hemorrhage are below the aortic bifurcation.