How to maxmize your resuscitation potential in trauma patients? ผศ.นพ.นเรนทร์ โชติรสนิรมิต

1. 11/26/14
1
HOW
TO
MAXIMIZE
YOUR
RESUSCITATION
POTENTIAL
IN
TRAUMA
PATIENTS
?
NARAIN
CHOTIROSNIRAMIT
MD.
TRAUMA
AND
CRITICAL
CARE
UNIT,
DEPARTMENT
OF
SURGERY,
FACULTY
OF
MEDICINE
CHIANGMAI
UNIVERSITY
INTRODUCTION
Populations
number
Number of
death
Estimated road
traffic death
rate per
100,000
populations
Niue
1,465
1
68.3
Dominican
Republic
9,927,320
2,470
40.1
Thailand
69,122,232
13,365
38.1
Venezuela
28,979,857
7,714
37.2
Iran
73,973,628
23,247
34.1
Nigeria
158,423,184
5,279
33.7
South
Africa
50,132,820
14,804
31.9
• PERMISSIVE
HYPOTENSION
• BEDSIDE
MONITORING
FOR
RESUSCITATION
• HEMOSTATIC
RESUSCITATION
• RESUSCITATIVE
ENDOVASCULAR
BALLOON
OCCLUSION
FOR
AORTA
PERMISSIVE
HYPOTENSION

2. 11/26/14
2
Kenneth
L.
MaYox
PERMISSIVE
HYPOTENSION
William
H.
Bickell,
et
al.
N
Engl
J
Med.
Volume
331,
Oct
1994
:1105-­‐1109
PERMISSIVE
HYPOTENSION
Single
center
,
prospecve
,
randomized
,
controlled
trial
in
Houston
1989-­‐1992.
598
adult
trauma
with
penetrang
torso
injury
&
SBP
<
90
mm
Hg.
1.
Immediate
resuscitaon
(
IR
)
2.
Delayed
resuscitaon
(DR)
PERMISSIVE
HYPOTENSION
“Hypotensive
paents
with
penetrang
injuries
of
the
chest
and
abdomen
:
Deferring
fluid
admin
:
improves
outcome”
William
H.
Bickell,
et
al.
N
Engl
J
Med.
Volume
331,
Oct
1994
:1105-­‐1109
PERMISSIVE
HYPOTENSION
Favorable
results
in
delayed
fluid
resuscitaon
Capone,
AC,
Safar,
P,
Stezoski,
W,
et
al.
J
Am
Coll
Surg
1995;
180:49
Owens,
TM,
Watson,
WC,
Prough,
DS,
et
al.
J
Trauma
1995;
39:200..
Silbergleit,
R,
Satz,
W,
McNamara,
RM,
et
al.
Acad
Emerg
Med
1996;
3:922.
Kim,
SH,
Stezoski,
SW,
Safar,
P,
et
al.
J
Trauma
1997;
42:213.
Solomonov,
E,
Hirsh,
M,
Yahiya,
A,
Krausz,
MM.
Crit
Care
Med
2000;
28:749.
DuZon,
RP,
Mackenzie,
CF,
Scalea,
TM.
J
Trauma
2002;
52:1141.
McKinley,
BA,
Valdivia,
A,
Moore,
FA.
Curr
Opin
Crit
Care
2003;
9:292.
Mapstone,
J,
Roberts,
I,
Evans,
P.
J
Trauma
2003;
55:571.
PERMISSIVE
HYPOTENSION
Excessive
crystalloid
:
can
cause
abdominal
compartment
syndrome
(ACS).
Normal
resuscitaon
:
decrease
incidence
of
ACS.
Balogh
,
Moore,
et
al.
Arch
Surg.
2003
Jun;138(6):637-­‐42

3. 11/26/14
3
for
Just
injury
penetrang
!!!
PERMISSIVE
HYPOTENSION
The
paent
who
would
probably
not
tolerate
prolonged
hypotension
1.
The
head-­‐injured
hypotensive
paent
2.
Blunt
trauma
paent
with
mulple
sites
of
blood
loss
3.
Extremely
old
PERMISSIVE
HYPOTENSION
BLUNT
TRAUMA
?
George
K,
et
al
J
Trauma
Acute
Care
Surg
Volume
74,
Number
5,
1215-­‐1222
George
K,
et
al
J
Trauma
Acute
Care
Surg
Volume
74,
Number
5,
1215-­‐1222
George
K,
et
al
J
Trauma
Acute
Care
Surg
Volume
74,
Number
5,
1215-­‐1222

4. 11/26/14
4
ALI/ARDS
MOF
ABD
COMPARTMENT
SSI
• High
CCOONNCCLLUUSSIOIONN
volume
of
crystalloid
resuscitaon
:
Prolonged
ven`lator
`me
Prolonged
ICU
stay
Prolonged
hospital
LOS
• Dose-­‐dependent
increase
morbid
complicaons
(ALI/ARDS,
MOF,
abdominal
compartment
syndrome,
SSIs)
PERMISSIVE
HYPOTENSION
HEAD
INJURY
?
PERMISSIVE
HYPOTENSION
HEAD
INJURY
?
• Impaired
cerebral
autoregulaon
due
to
TBI
makes
cerebral
perfusion
dependent
on
adequacy
of
sBP
• sBP
<
90
mmHg
early
aoer
TBI
:
150%
increase
in
mortality
Chesnut
RM,
Marshall
LF,
Klauber
MR,
et
al.
J
Trauma
1993;34:216–22
PERMISSIVE
HYPOTENSION
TARGET
BLOOD
PREESURE
?
PERMISSIVE
HYPOTENSION
TARGET
BLOOD
PREESURE
?
Fluid
administraon
to
maintain
the
MAP
in
the
60-­‐80
mmHg
range
is
advisable
and
appropriate.
Hai
SA.J
Pak
Med
Assoc.
2004
Aug;54(8):434-­‐6.

5. 11/26/14
5
PERMISSIVE
HYPOTENSION
TARGET
BLOOD
PREESURE
?
• 80
rats
8
groups :
Different
target
MAPs
(control,
40,
50,
60,
70,
80,
90
mmHg,
and
sham)
on
fluid
resuscitaon
of
uncontrolled
hemorrhagic
shock.
PERMISSIVE
HYPOTENSION
TARGET
BLOOD
PREESURE
?
• Conclusion
Too-­‐low
MAP
resuscitaon
results
in
Less
blood
loss
and
lower
fluid
therapy
Greater
proinflammatory
cytokine
response
Higher
mortality
than
resuscitaon
at
higher
MAP
of
uncontrolled
hemorrhagic
shock.
MAP
of
60
mmHg
is
the
target
BP
for
hypotensive
resuscitaon.
PERMISSIVE
HYPOTENSION
TARGET
BLOOD
PREESURE
?
PERMISSIVE
HYPOTENSION
TARGET
BLOOD
PREESURE
?
Uncontrolled
hemorrhage,
hypotensive
resuscitaon
to
MAP
60
mmHg
may
be
the
opmal
target
MAP
Yu
YH,
et
al.
Resuscita`on
2009;80:1424–30.
WARNING
If
Bleeding
stop
No
Permissive
hypotension

6. 11/26/14
6
BEDSIDE
MONITORING
OF
RESUSCITATION
FAST
Extend
to
Rt/Lt
Chest
Cavity
E-­‐FAST
• Hemothorax
• Pneumothorax
sensivity
92-­‐100%
specificity
91-­‐100%
Husain
LF,
Hagopian
L,
Wayman
D,
Baker
WE,
Carmody
KA.
Sonographic
diagnosis
of
pneumothorax.
J
Emerg
Trauma
Shock.
2012;5(1):76–81.
Sign
of
Pneumothorax
-­‐ Loss
of
lung
sliding
sign
-­‐ “Absent
of
Seashore
sign”
or
“Stratosphere
sign”
or
“Barcode
sign”
Rao
R.
Ivatury

7. 11/26/14
7
BEDSIDE
MONITORING
OF
RESUSCITATION
BEDSIDE
MONITORING
OF
RESUSCITATION
Invasive
hemodynamic
monitoring
in
the
trauma
bay
?
BEDSIDE
MONITORING
OF
RESUSCITATION
Underresuscitaon
&
overresuscitaon
have
life-­‐threatening
consequences.
Balogh
Z,et
al.
Am
J
Surg.
2002;184:538Y543.
Kasotakis
G,
et
al.
J
Trauma
Acute
Care
Surg.
2013;74:1215-­‐1221.
BEDSIDE
MONITORING
OF
RESUSCITATION
Hypothesis
:
LTTE
is
a
useful
tool
to
guide
therapy
in
hypotensive
trauma
paents
during
the
inial
phase
of
resuscitaon
PATIENTS
AND
METHODS
• Paents
at
any
point
during
the
inial
presentaon
or
en
route
had
:
sBP
<
100
mmHg
Mean
BP
<
60mmHg
Pulse
>
120
beats
/min
Randomized
:
LTTE
performed
(LTTEp)
Not
performed
(non-­‐LTTE)
1St
July
–
31st
December
2012.
BEDSIDE
MONITORING
OF
RESUSCITATION
• Windows
obtained
included
the
following:
Parasternal
long
Parasternal
short
Apical
and
subxyphoid.

8. 11/26/14
8
BEDSIDE
MONITORING
OF
RESUSCITATION
• Reporng
the
Results
of
the
LTTE
Contraclity
Fluid
status
Pericardial
effusion.
• Fluid
BEDSIDE
MONITORING
OF
RESUSCITATION
Status
IVC
size
and
collapsibility
Hypovolemic
:
IVC
<
2
cm
and
collapsible.
Ventricular
filling
Hypovolemia
:
Hyperdynamic
heart.
(ventricle
that
is
closing
nearly
100%,with
almost
no
blood
at
the
end
of
systole)
Collapsible
inferior
vena
cava,
long
axis
view
Inferior
vena
cava
plethora
long
axis
view
Fluid
Status
Inferior
vena
cava
assessment
Spontaneous
breathing
IVCD
(mm)
à
Collapsibility
Caval
Index
(%)
RAP
(mmHg)
<
20
>
50
5
<
20
<
50
10
>
20
<
50
15
>
20
0
20
Gunst
et
al.
Bedside
Echocardiographic
Assessment
for
Trauma/Cri;cal
Care:
The
BEAT
Exam.
J
Am
Coll
Surg
Vol.
207,
No.
3,
Sep
2008

9. 11/26/14
9
BEDSIDE
MONITORING
OF
RESUSCITATION
• Contraclity
Good
or
poor.
No
calculaons
of
the
ejecon
fracon
No
comments
of
ventricular
wall
moon
abnormalies.
Assessment
of
global
heart
funcon
only.
M-­‐mode
tracing
demonstrang
excellent
contraclity.
RV:
right
ventricle,
LV:
leo
ventricle
M-­‐mode
tracing
demonstrang
poor
contraclity.
LV:
leo
ventricle
• Pericardial
Effusion
Presence
or
the
absence
of
effusion
only
No
commenng
on
the
physiology
of
the
heart.
BEDSIDE
MONITORING
OF
RESUSCITATION
Cardiac
tamponade,
subxiphoid
view.
RV:
right
ventricle,
RV:
right
atrium,
LV:
leo
ventricle,
LA:
leo
atrium,
PE:
pericardial
effusion
215
paents
in
the
study.
92
LTTEp
123
non-­‐LTTE

10. 11/26/14
10
BEDSIDE
MONITORING
OF
RESUSCITATION
Conclusion
• LTTE
was
a
useful
tool
to
guide
therapy.
The
LTTEp
group
to
receive
less
IVF
and
aided
in
the
resuscitaon
process.
• The
appropriate
image-­‐guided
resuscitaon
perhaps
contributed
to
decreased
mortality
in
the
LTTEp
group
HEMOSTATIC
RESUSCITATION
Initial Assessment and Management
INTERVENTIONS
What can I do about shock?
Direct
pressure/
tourniquet
Reduce pelvic
volume
Operation
Hemostatic Agents
Hemostatic
resuscitation
Angio-embolization
Splint fractures
9th
Damage
Control
Resuscitaon
Hemostac
Resuscitaon
/
Balanced
Blood
Product
Resuscitaon
DCR
Permissive
Hypotension
/
Restricve
Fluid
Resuscitaon
Damage
Control
Operaon
/
Surgery
(DCO
/
DCS)
John
B
Holcomb

11. 11/26/14
11
Timing
and
mechanism
of
traumac
death.
Kauvar
DS,
Lefering
R,
Wade
CE.
J
Trauma.
2006;60:S3–S11.
Coagulopahy
in
trauma
paents
Lethal
triads
Coagulopathy
Acidosis
Hypothermia
Damage
Control
Resuscitaon
Up
to
30%
of
blood
transfused
case
require
a
massive
transfusion
(
>
10
u
of
blood
in
the
first
24
hrs
of
admission)
Como
JJ,
DuYon
RP,
Scalea
TM,
et
al.
Transfusion.
2004;
44:809–813.
Malone
DL,
Dunne
J,
Tracy
Jk,
et
al.
J
Trauma.
2003;54:898
–905.
Massive
Transfusion
1–3%
of
civilian
trauma
Mortality
rates
50–70%
Fakhry
SM,
Sheldon
GF.
American
Associa`on
of
Blood
Banks,
1994.
Bri`sh
CommiZee
for
Standards
in
Haematology.
BrJ
Haematol
2006;
135:634-­‐41
Acute
traumacc
coagulopathy
(ATC)
Acute
coagulopathy
of
trauma
is
ooen
present
before
any
resuscitave
efforts
Brohi
K,
Singh
J,
Heron
M,
Coats
T.
J
Trauma.
2003;54:1127–1130.
MacLeaod
JB,
Lynn
M,
McKenney
MG,
et
al.
J
Trauma.
2003;
55:39–44.

12. 11/26/14
12
•
Prospecve,
observaonal
study
•
Populaons:
45
trauma
paents
•
Compare:
the
on-­‐scene
coagulaon
profile
at
the
scene
of
the
accident,
before
fluid
administraon,
and
on
hospital
admission
On
Scene
ER
Relaon
between
coagulaon
status
and
injury
severity
score
on-­‐scene
and
in
the
emergency
room.
Acute
traumacc
coagulopathy
(ATC)
Conclusion
:
Coagulacon
abnormalices
Appear
very
early
ader
injury
Before
fluid
administracon
60%
of
pacents.
Upon
hospital
admission,
the
on-­‐scene
coagulopathy
was
the
same
or
worsened
in
96%
of
the
pacents
Acute
traumacc
coagulopathy
(ATC)
Trauma
+
Shock
• Trauma
– Increase
ssue
injury,
inflammaon
– Increase
thrombin
producon
• Cleave
fibrinogen
to
fibrin
• Potenate
procoagulant
process
• Acvaon
of
protein
C
– Consumpve
coagulopathy
• Hypoperfusion
– Elevate
levels
of
protein
C
– Elevate
thrombomodulin
-­‐>
Thrombomodulin-­‐bound
thrombin
• Acvaon
of
protein
C
• Impairing
clot
formaon
• Fibrinolysis
is
enhanced
– Release
of
t-­‐PA
from
vascular
endothelial
cells
and
subsequent
hyperfibrinolysis
How
can
we
predict
of
MT
?
Clinical
scoring
system

13. 11/26/14
13
TASH
Score
TASH
Score
McLaughlin
score
McLaughlin
score
McLaughlin
DF.
J
Trauma.
2008;64:S57–S63.
ABC
score
ABC
score

14. 11/26/14
14
ABC
score
ABC
>
2,
75%
sensicve,
86%
specific
ABC
TASH
McLaughlin
Hsu
et
al.
Prediccve
Tools
for
MT
in
Trauma
BP
≤
90
SBP
(categorical)
<
110
Hct
<
32%
pH
<
7.25
-­‐
HR
≥
120
>
120
>
105
-­‐
FAST
FAST+
FAST+
-­‐
FAST+
Mechanism
Penetracng
Complex
long
bone
or
pelvic
Fx
-­‐
-­‐
Demographics
-­‐
Male
-­‐
-­‐
LAB
-­‐
Hb
(categorical),
BE
(categorical)
Hct
<
32%
pH
<
7.25
BE
<
-­‐5
INR
>
1.5
AUROC
0.859
0.887
0.747
0.859
RESULT
RESULT
Riskin
DJ,
Tsai
TC,
Riskin
L,
et
al.
J
Am
Coll
Surg.
209(
2),
August
2009,
198-­‐205
PRC:FFP:Plt
rao
=
1:1:1
• Lower
the
mortality
• High
raco
of
FFP:
Early
studies
showed
• Higher
ARDS
and
MOF
incidences
• Higher
complicacons
(Sepcc
shock,
VAP,
abdominal
compartment
syndrome,
ACS,
heart
failure,
liver
failure)
J
Am
Coll
Surg.
2009;209(2):198–205.
PROMMTT
Study.
JAMA
Surg
2013;
148(2):127-­‐136.
Retrospecve
mulcenter
cohort
study
of
437
massively
transfused
trauma
paents
Brown
LM.
J
Trauma.
2011;71:
S358–S363

15. 11/26/14
15
METHOD
• Included
studies
1613
references
were
1532
references
were
excluded
81
arcles
obtained
Final
8
arcles
• This
CONCLUSION
meta-­‐analysis
supports
the
use
of
plasma
in
raos
of
1:2
plasma:RBC
• Did
not
idenfy
addional
benefits
of
1:1
over
1:2
transfusion
raos.
OTHER
HEMOSTATIC
AGENTS
r
FACTOR
VII
RCT
in
301
paents
with
severe
blunt
and/or
penetrang
trauma
Significant
reducon
of
red
cell
transfusion
Mortality
:
not
significant
Boffard
KD.
J
Trauma
2005;59:8-­‐15
CRYOPRECIPITATE
• In
the
resuscitaon
of
bleeding
trauma
paents
Early
fibrinogen
infusion
associated
with
favorable
outcomes
in
uncontrolled
studies
Rourke
C,
et
al.
J
Thromb
Haemost.
2012;10:1342Y1351.
Schochl
H,
et
al.
Crit
Care.
2011;
15:R83.
Shakur
H,
et
al.
Lancet
2010;
376(9734):23.

16. 11/26/14
16
ANTIFRIBINOLYTIC
THERAPY
Randomized
controlled,
mulc-­‐center
trial
274
hospitals
,
n
=
20,211
trauma
pts.
Result:
28-­‐day
Mortality
Rate:
14.5% vs.
16%
;
p
=
0.0035
Loading dose of 1g over 10 min.
then 1g infusion for 8 hrs
vs. Placebo
Mortality
rate
from
uncontrolled
bleeding:
4.9% vs.
5.7% ;
p
=
0.0077
Mortality
rate
in
trauma(ader
3
hrs):
4.4%
vs.
3.1%
;
p=0.004
Shakur
H,
et
al.
Lancet
2010;
376(9734):23.
MASSIVE
TRANSFUSION
PROTOCOL
MAHARAJ
NAKORN
CHIANGMAI
2
FEBRUARY
2014
MTP
Maharaj
Nakorn
Chiangmai
MTP
Maharaj
Nakorn
Chiangmai
Indicaons
for
ER
Inial
resuscitaon
>
2
liters
of
isotonic
crystalloid
ร่วมกับมีข้อใด
ข้อหนึ่งต่อไปนี้
HR
>
120
bpm
sBP
<
90
mmHg
Serum
pH
<
7.2
Base
excess
<
-­‐5
PRC
:
FFP
:
Plt
=
4:2:2
1
2

17. 11/26/14
17
3
4
MTP
Maharaj
Nakorn
Chiangmai
• 1
Box
of
MTP
=
PRC:FFP:Plt
=
4:2:2
(PRC
-­‐>
inial
crossmatch/first-­‐stage)
• Need
15
min
for
1st
box
• BOX
3
:
full
crossmatch
5
6
7
8
9
10
ข้อมูล
กพ-­‐ตค
2557
เพศ
ช่วงอายุ
ช
ญ
ผลรวมทั้งหมด
10-­‐19
10
0
10
20-­‐29
12
2
14
30-­‐39
13
0
13
40-­‐49
8
3
11
50-­‐59
13
2
15
60-­‐69
3
0
3
70-­‐79
4
0
4
80-­‐89
2
0
2
ไม่ทราบอายุ
3
0
3
ผลรวมทั้งหมด
68
7
75
MTP
Maharaj
Nakorn
Chiangmai
Type
In
1
hr
2nd
hr
>
2
hr
Total
PRC
316
98
425
839
FFP
188
42
321
551
Plt
178
53
292
523
Cryo
20
0
80
100
MTP
Maharaj
Nakorn
Chiangmai
Resuscitave
Endovascular
Balloon
Occlusion
of
the
Aorta
(REBOA)

18. 11/26/14
18
REBOA
Balloon
occlusion
:
an
adjunct
for
shock
was
reported
during
the
Korean
War.
Hughes
CW..
Surgery.
1954;36:65-­‐68.
• Raonale
:
REBOA
Aorc
occlusion
supports
myocardial
and
cerebral
perfusion
unl
resuscitaon
can
be
iniated
and
hemostasis
obtained.
Same
goals
of
open
aorc
cross
clamping.
REBOA
:
less
invasive
,
decrease
morbidity.
White
JM,
et
al.
Surgery.
2011;150:400-­‐409.
Burlew
CC,
et
al.
J
Trauma
Acute
Care
Surg.
2012;73(6):
1359-­‐1363;
discussion
1363-­‐1364.
Dorlac
WC,
et
al.
J
Trauma.
2005;59(1):217-­‐222.
Intraoperave
angiogram
performed
through
a
side-­‐port
of
the
sheath
demonstrates
renal
arteries
aoer
stent
deployment
with
balloon
sll
inflated
O’Donnell
ME
et
al.
J
Vasc
Surg,
44(1),
211-­‐5
REBOA
Aorc
balloon
have
also
been
used
to
control
hemorrhage
in
civilian
abdominal
trauma.
Gupta
BK,
et
al.
J
Trauma
1989;
29
:
861-­‐5
Wolf
Rk,
et
al.
J
Vasc
Surg
1986;
4:
95-­‐7.
REBOA
5
steps
each
with
specific
procedural
consideraons
1.
Arterial
access
2.
Balloon
selecon
and
posioning
3.
Balloon
inflaon
4.
Balloon
deflaon
5.
Sheath
removal
Step
1

19. 11/26/14
19
• STEP
REBOA
2:
SELECTION
AND
POSITIONING
OF
THE
BALLOON
Selecon
of
a
Balloon
:
Examples
of
compliant
balloons
(1)
Coda
balloon
(Cook
Medical):
32-­‐40
mm,
14
Fr
(2)
Reliant
balloon
(Medtronic):
10-­‐46
mm,
12
Fr
(3)
Berenstein
balloon
(Boston
Scien`fic):
11.5
mm,
6
Fr.
Step
2
Step
2
Pelvic
binder
in
place
with
REBOA
catheter
in
right
groin.
Binder
was
moved
up
and
modified
to
facilitate
placement
of
REBOA.
• STEP
REBOA
3:
INFLATION
OF
THE
BALLOON
AND
SECURING
OF
THE
APPARATUS
Inflaon
of
the
Balloon
(should
be
under
fluoroscopic
guidance).
Mix
:
1⁄2
&
1⁄2
soluon
of
sterile
saline
and
iodinated
contrast.
Assistant
should
monitor
and
communicate
the
“big
three”
factors
for
successful
REBOA:
1.
mean
arterial
pressure
2.
maintenance
of
posi`on
3.
maintenance
of
occlusion
(balloon
infla`on).
REBOA

20. 11/26/14
20
• STEP
REBOA
4:
DEFLATION
OF
THE
BALLOON
Reperfusion
syndrome.
• STEP
5:
REMOVAL
OF
THE
BALLOON
AND
SHEATH
Closure
of
the
arteriotomy
site
(suture)
• Aorc
REBOA
occlusion
me
of
40
mins.
Opmal
to
control
hemorrhagic
shock
Prevenng
the
biological
side
effects
of
the
ischemia/reperfusion
injury.
Jean-­‐Philippe
Avaro,
et
al.
J
Trauma
.
2011
:
71
(3)
Brenner
ML,
Moore
LJ,
Dubose
JJ,
et
al.
J
Trauma.
2013
Sept
75(3),
506-­‐511
Paent
1
2
3
4
5
6
Age
62
24
59
25
40
27
Sex
M
M
M
M
M
F
Mechanism
injury
MVC
GSW
GSW
MVC
MCC
ATV
Injury
Severity
Score
(ISS)
28
50
9
25
48
43
SBP
before
REBOA
70
70
0
60
70
85
SBP
aoer
REBOA
135
122
100
110
130
125
Cardiac
arrest
before
REBOA
No
No
Yes
No
No
NO
Time
to
occlusion
5
4
4
6
6
6
Time
of
occlusion
12
16
70
60
65
36
Outcome
Alive
Alive
Alive
Alive
Brain
death
Death
Brenner
ML,
Moore
LJ,
Dubose
JJ,
et
al.
J
Trauma.
2013
Sept
75(3),
506-­‐511

21. 11/26/14
21
• REBOA
REBOA
resulted
in
:
Mean
(SD)
increase
in
BP
of
55
(20)
mm
Hg
Mean
(SD)
aorc
occlusion
me
was
18
(34)
mins.
No
REBOA-­‐related
complicaons.
No
hemorrhage-­‐related
mortality.
Brenner
ML,
Moore
LJ,
Dubose
JJ,
et
al.
J
Trauma.
2013
Sept
75(3),
506-­‐511
The
Endovascular
Skills
for
Trauma
and
Resuscitave
Surgery
(ESTARS)
curriculum
has
been
developed.
Stannard
A,
et
al
.
J
Trauma.
2011;71(6):1869-­‐1872.
Villamaria
CY,
et
al.
72nd
Annual
Mee`ng
of
the
AAST
and
Clinical
Congress
of
Acute
Care
Surgery.
BEST
course
ALL
PERFORM
IN
OR
(NEED
FLUOROSCOPY)
POSSIBLE
IN
ER
?
ScoZ
DJ,
et
al.
J
Trauma
Acute
Care
Surg.
Volume
75,
Number
1
122-­‐128

22. 11/26/14
22
Accurate
balloon
posioning
87.5%
VS
100%.
One
device
entered
a
right
renal
artery
Similar
increases
in
MAP,
carod
blood
flow,
and
paral
pressure
of
brain
oxygenaon
REBOA
POSSIBLE
TO
DO
IN
ER
Trauma
with
Hypotension
(Extremis)
Access
Common
Femoral
artery
for
A-­‐Line
or
REBOA
CXR
NO
REBOA
YES
NO
Possible
Aorcc
injury
?
FAST
Posicve
?
YES
Posicon
REBOA
in
Zone
I
Inflate
and
proceed
to
laparotomy
NO
Pelvic
X-­‐RAY
Fracture
?
Posicon
REBOA
in
Zone
I
Inflate
and
Resuscitate
YES
Posicon
REBOA
in
Zone
III
Inflate
and
Resuscitate
NO
• PERMISSIVE
HYPOTENSION
• BEDSIDE
MONITORING
FOR
RESUSCITATION
• HEMOSTATIC
RESUSCITATION
• RESUSCITATIVE
ENDOVASCULAR
BALLOON
OCCLUSION
FOR
AORTA

23. 11/26/14
23
สรุป%
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YOU