This was a retrospective analysis of the aortic balloon occlusion (ABO) (founded in Sweden, 13 countries) and AORTA (AAST sponsored, USA) registries over a total of approximately 10 years leading up to 2021 (the time periods did not entirely overlap between datasets, but came close). By definition, all patients in the cohort underwent REBOA placement. Several clinical outcomes were measured, with the primary outcome of 24-hour mortality. The authors performed several statistical analyses, including the relatively novel approach of using fractional polynomials to plot the probability of death vs pre-REBOA SBP. This allows for non-linear and flexible relationships between predictors and outcomes in a regression model. Areas under the receiver operating curve (ROC) were used to test the discriminative ability of SBP to predict mortality. Finally, multivariable Poisson analyses were performed, testing SBP cut points at every 10 mmHg for their associated relative risk of mortality.
After exclusions, 848 patients were analyzed. 19.9% had a penetrating mechanism and 32% died within 24 hours. The fractional polynomial analysis resulted in a U-shaped curve with the lowest probabilities of mortality associated with pre-REBOA SBP between 60 and 90. The ROC for the crude relationship between SBP and mortality was a modest discriminator with an AUC of 0.599. Formal cut point testing demonstrated optimal performance somewhere between 50 and 70, suggesting that a SBP in this range may be the best predictor of salvageability. The Poisson models demonstrated higher relative risks of death at 60, 70, and 80 mmHg pre-REBOA, without a significantly increased RR at 90 mmHg. Based on these results, the authors conclude that patients with pre-REBOA SBPs of 60-80 mmHg may benefit most from REBOA placement.
This is an important contribution to the ever-controversial REBOA literature and may help guide decision-making for some. Of course, this is far from a definitive word on the issue. The combination of both penetrating and blunt patients, as well as zone 1 (about 2/3 of the cohort) and zone 3 patients in one analysis makes it difficult to know how to apply this data. Perhaps most importantly, there is no comparison in this retrospective analysis of two REBOA-specific databases – i.e., we do not know whether or not the patients with SBPs 60-80 would have done better without REBOA. Despite lingering questions, this novel look at one of the largest REBOA cohorts to date helps shed some light on the issue.
This is an analysis of Boston Police Department data from 2005-2023, in which the authors mapped locations of firearm assaults involving victims over 14 years old and calculated predicted ground transport times to the nearest trauma center using geographic information system software and incorporating trauma center location and EMS station location. Spatial regression models used to define the relationships between race, distance to trauma center, and mortality. Finally, an additional analysis was performed in which every shooting’s transport time was set to that of the median white victim, to determine how this might have changed influenced outcomes.
The first figure in the paper is an overall depiction of shooting locations relative to trauma centers, with color-coded zones representing predicted transport times. What is immediately apparent is that the majority of shootings take place in the southern part of the city, relatively remote from the trauma centers. Those who died had a median predicted transport time of 10.5 minutes and those who survived had a median transport time of 9.4 minutes. Multivariable logistic spatial autoregressive analysis revealed that transport time and age were significant predictors of mortality. Perhaps the most profound part of this manuscript is a row in Table 2, in which it is demonstrated that Black non-Hispanic victims had the longest transport time to a trauma center (median 10.1 minutes), followed by Black Hispanic, followed by white Hispanic, finally followed by white non-Hispanic patients with a median time of 8.3 minutes. In the final portion of their analysis, the authors demonstrated hypothetical decreases in mortality rates when all racial groups had their transport times set to the median White non-Hispanic transport time. These decreases were modest but real.
This is another important examination of the impact of race and social inequity on trauma outcomes by the BU group. There are obvious limitations, including the lack of clinical data (beyond mortality) and the lack of actual transport times (only those predicted from distances using GIS). However, the creative mapping of the data provides a stark visual of the issue at hand, and the use of a spatial autoregressive logit model increases the strength of the analysis by mitigating some of the spatial autocorrelation inherent in this data. This is a valuable contribution to the literature that provokes thought about the structure of urban trauma systems.
Blunt thoracic aortic injury (BTAI) is one of the leading causes of death after trauma. Historically, these have been treated with open surgical repair, but have been increasingly treated with endovascular techniques, such as thoracic endovascular aortic repair (TEVAR), which carry a much lower cost of morbidity and mortality. However, these endovascular techniques are not without their own complications. Medical management for low-grade injuries (grades I and II) has been associated with an extremely low risk of failure (PMID 34560220). The Aortic Trauma Foundation (ATF) is a multicenter trauma registry that collects data prospectively on the diagnosis, management, and outcomes after BTAI from more than 40 centers. This paper used the ATF registry to compare patient outcomes (mortality, aortic-related mortality, hospital and ICU lengths of stay) who were treated with TEVAR vs. medical management alone over the most recent 6 year period.
Over the study period, 274 patients were identified with grade I or II injuries. Five of these patients progressed on imaging, requiring subsequent TEVAR, and were excluded from analysis. The remaining 269 patients were analyzed. Two hundred eighteen patients (81%) were managed non-operatively, while 51 (19%) were managed with TEVAR. When examining the management strategy by grade, 95% of grade 1 injuries were management with medical management, while management of grade II injuries were fairly evenly split. Additional data collected included demographics, mechanism of injury, admission physiology, Abbreviated Injury Scale scores, Injury Severity Score, need for other operative intervention, and transfusion requirements. Admission systolic blood pressure was lower among patients undergoing TEVAR (114 vs. 124, p=0.035); rates of need for laparotomy was also higher among patients undergoing TEVAR (31% vs 15%, p=0.007). Other variables were not statistically significantly different across the two patient populations. Overall mortality rates were lower among patients undergoing medical management (8% vs. 18% p=0.009), while aortic-related mortality was not statistically different (0.5% vs. 4%, p=0.06). Using a multivariable regression model that controls for age, sex, admission SBP, ISS, GCS, and rates of laparotomy, there was no difference in mortality between management strategies (OR 0.82, 95% CI 0.25-2.67).
This study demonstrates that in low-grade BTAI, medical management alone is, at a minimum, not inferior to TEVAR. While the authors highlight the lower overall and aortic-related mortality rates favoring medical management, there is no statistical difference between the two groups in a multivariable regression analysis comparing the two management strategies when controlling for other confounding variables. This study is limited by the fact that it is not a randomized control trial, but the data here advocates that there is equipoise that would make that possible.
Initial management of splenic injuries has increasingly transitioned to non-operative management with the use of adjunctive measures, such as angioembolization. Failure of non-operative management has been associated with higher grade of injury and other factors, such as presence of vascular injury, often identified on CT imaging as a “contrast blush”. The American Association for the Surgery of Trauma (AAST) spleen injury scale is commonly used as a tool to decide among management strategies. Low grade injuries had the lowest rate of failure of non-operative management, regardless of use of angioembolization. While the presence of a vascular injury was associated with higher rates of splenectomy, prior to 2018, the presence of a vascular injury was not a consideration on the AAST grading scale. The purpose of this study was to evaluate the risk of failure in low grade splenic injuries with a contrast blush.
This was a retrospective cohort study of adult patients with a grade I or II blunt splenic injury with a contrast blush on CT imaging from 21 institutions over a nearly 6 year period (1/2014-10/2019) that were treated with non-operative management, which was defined as no planned operative or angiographic interventions. Patients under the age of 18 were excluded, as well as those with hemodynamic instability, known bleeding disorders, or medication-induced coagulopathy, such as antiplatelet or antithrombotic medication use. The primary outcome was failure of non-operative management, which was the need for delayed operative or angiographic interventions. One hundred forty-five patients were identified. Twenty-nine (20%) failed non-operative management, while 116 (80%) were successfully managed non-operatively. When comparing those that failed non-operative management with those that were successfully managed non-operatively, those that failed had a higher rate of need for blood transfusion and initiation of massive transfusion protocol. Overall, those that failed had longer hospital lengths of stay. There was no difference in location of the contrast blush (inside, outside, or both inside and outside the splenic parenchyma). In addition, the rates of failure by grade were also not statistically different (grade I 18%, grade II 21%). Time to need for intervention was most commonly within 12 hours (69%).
This data was collected prior to the 2018 AAST spleen injury scale update, which identifies a vascular injury as a grade IV or V injury, depending on whether the bleeding extended beyond the splenic capsule or not. This study confirms this revision, as the presence of a vascular injury, even in low-grade injuries, more closely mimics those of higher-grade injuries.
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