Prehospital Z1 P-REBOA Feasible and may enable early survival in Trauma Patients: JAMA

"In the cohort study involving 16 patients with severe injuries and shock, prehospital zone 1 (supraceliac) partial resuscitative endovascular balloon occlusion of the aorta (Z1 P-REBOA) was successfully administered in 8 out of 11 patients who underwent Z1 REBOA. This approach correlated with enhanced proximal blood pressure (BP) levels and reduced early mortality rates," the researchers reported.

Hemorrhage is the leading preventable cause of death following injury, with the majority occurring during the early prehospital phase of treatment. The P-REBOA procedure involves temporarily inflating a balloon in the aorta to halt blood flow beyond the injury site, thereby stabilizing the patient and buying crucial time for definitive surgical intervention. This approach is particularly crucial for trauma cases where rapid blood loss threatens life within minutes.

Robbie A. Lendrum from Bart’s Health National Health Service Trust in London, United Kingdom, and colleagues aimed to establish whether prehospital zone 1 (supraceliac) partial resuscitative endovascular balloon occlusion of the aorta can be achieved in the resuscitation of adult trauma patients at cardiac arrest and death risk due to exsanguination.

For this purpose, the researchers conducted a prospective observational cohort study with recruitment from 2020 to 2022 and follow-up until death, discharge from the hospital, or 90 days evaluating a physician-led and physician-delivered, urban prehospital trauma service in the Greater London area.

It included trauma patients 16 years and older age with suspected exsanguinating subdiaphragmatic hemorrhage, and recent or imminent hypovolemic traumatic cardiac arrest (TCA). It excluded those with unsurvivable injuries or who were pregnant. Of the 2960 individuals served during the study period, 16 were selected for inclusion.

The primary focus was determining the success rates of achieving Z1 REBOA and Z1 P-REBOA among patients. The key clinical endpoints assessed included the response of systolic BP to Z1 REBOA, mortality rates at various intervals post-injury (1 hour, 3 hours, 24 hours, or 30 days), and the survival rate to hospital discharge.

The study led to the following findings:

• Femoral arterial access for Z1 REBOA was attempted in 16 patients (median age, 30 years; 81% male; median Injury Severity Score, 50).
• In 2 patients with successful arterial access, REBOA was not attempted due to improvement in clinical condition.
• In the other 14 patients (8 of whom were in traumatic cardiac arrest [TCA]), 11 successfully underwent cannulation and had aortic balloons inflated in Z1.
• The three individuals in whom cannulation was unsuccessful were in TCA (failure rate = 3/14 [21%]).
• The median pre-REBOA SBP in the 11 individuals for whom cannulation was successful (5 [46%] in TCA) was 47 mm Hg.
• Z1 REBOA plus P-REBOA was associated with a significant improvement in BP (median SBP at emergency department arrival, 101 mm Hg; 0 of 10 patients were in TCA at arrival).
• The median group-level improvement in SBP from the pre-REBOA value was 52 mm Hg.
• P-REBOA was feasible in 8 individuals (8/11 [73%]) and occurred spontaneously in 4.
• The 1- and 3-hour postinjury mortality rate was 9%, 24-hour mortality was 27%, and 30-day mortality was 82%.
• Survival to hospital discharge was 18%. Both survivors underwent early Z1 P-REBOA.

The study showed the feasibility of prehospital Z1 P-REBOA using distal pressure as a surrogate for flow for the resuscitation of exsanguinating trauma patients at risk of imminent prehospital death.

"This approach led to higher proximal blood pressure levels, maintained hemodynamic stability, and potentially facilitated early survival. However, it was also associated with a notable incidence of multiple organ dysfunction syndrome and delayed mortality," the researchers concluded.

Reference:

Lendrum RA, Perkins Z, Marsden M, et al. Prehospital Partial Resuscitative Endovascular Balloon Occlusion of the Aorta for Exsanguinating Subdiaphragmatic Hemorrhage. JAMA Surg. Published online July 10, 2024. doi:10.1001/jamasurg.2024.2254