R. P. Dumas1, D. N. Holena1, B. P. Smith1, M. J. Seamon1, P. M. Reilly1, Z. Qasim2, J. W. Cannon1 1University Of Pennsylvania,Division Of Traumatology, Surgical Critical Care And Emergency Surgery,Philadelphia, PA, USA 2University Of Pennsylvania,Division Of Emergency Medicine,Philadelphia, PA, USA
Introduction:
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has shown benefit as a less invasive bridge to hemorrhage control in patients with torso trauma. The number of patients who might benefit from this procedure and the need for this intervention in an urban trauma center however, remains unclear. We sought to develop a generalizable methodology to identify the number of patients with injuries and presenting physiology amenable to REBOA, with the intention of characterizing the accuracy of our algorithm compared to traditional chart review.
Methods:
We queried the database of our Level I trauma center for all patients presenting from 2014-2015. Potential REBOA patients were included based on anatomic injuries and physiology. ICD-9 codes were used to identify REBOA-amenable injury patterns (abdominal solid organ; traumatic lower extremity amputation; major abdominal or lower extremity vascular injury; pelvic fractures) and physiology (presenting systolic pressure of ≤90 mmHg or transfusion requirement during initial trauma resuscitation). We excluded patients with injuries contraindicating REBOA (major vascular neck, thoracic, and axillary injuries). Chart review was used to confirm that our algorithm correctly identified these patients. Two reviewers experienced in REBOA then performed chart review to adjudicate algorithm-identified cases.
Results:
4818 patients were admitted from 2014-2015. 666 patients were included based on injury pattern. 186 patients received blood transfusions. 149 patients had an initial systolic blood pressure ≤90 mmHg. 309 patients had contraindications to REBOA (FIGURE 1). 64 patients (79.7% male, 67.2% African-American, 53% penetrating mechanism of injury, median ISS 18.5 [IQR 14-28]) had an injury pattern and physiology amenable to REBOA with no injury contraindications. Chart review confirmed that our algorithm correctly identified 54 (86%) of patients that had anatomic injuries amenable to REBOA with no contraindications. Review by two independent REBOA-experienced physicians revealed 29 patients (46% of those identified by algorithm) that may have benefited from REBOA. The inter-rater reliability was excellent (kappa 0.94, p<0.001). In the total cohort, 0.6% of patients may have benefited from REBOA.
Conclusion:
Our REBOA algorithm identified patients who may have benefited from early femoral arterial access but over-estimated the number of true REBOA candidates. Centers seeking to establish a REBOA program should combine an algorithm to identify potential patients with a detailed chart review to determine their center-specific REBOA candidate population. Future work should focus on revision and refinement of this algorithm for application at other institutions.
