Prehospital Partial Resuscitative Endovascular Balloon Occlusion of the Aorta for Exsanguinating Subdiaphragmatic Hemorrhage.

Importance: Hemorrhage is the most common cause of preventable death after injury. Most deaths occur early, in the prehospital phase of care. Objective: To establish whether prehospital zone 1 (supraceliac) partial resuscitative endovascular balloon occlusion of the aorta (Z1 P-REBOA) can be achieved in the resuscitation of adult trauma patients at risk of cardiac arrest and death due to exsanguination. Design, Setting, and Participants: This was a prospective observational cohort study (Idea, Development, Exploration, Assessment and Long-term follow-up [IDEAL] 2A design) with recruitment from June 2020 to March 2022 and follow-up until discharge from hospital, death, or 90 days evaluating a physician-led and physician-delivered, urban prehospital trauma service in the Greater London area. Trauma patients aged 16 years and older with suspected exsanguinating subdiaphragmatic hemorrhage, recent or imminent hypovolemic traumatic cardiac arrest (TCA) were included. Those with unsurvivable injuries or who were pregnant were excluded. Of 2960 individuals attended by the service during the study period, 16 were included in the study. Exposures: ZI REBOA or P-REBOA. Main Outcomes and Measures: The main outcome was the proportion of patients in whom Z1 REBOA and Z1 P-REBOA were achieved. Clinical end points included systolic blood pressure (SBP) response to Z1 REBOA, mortality rate (1 hour, 3 hours, 24 hours, or 30 days postinjury), and survival to hospital discharge. Results: Femoral arterial access for Z1 REBOA was attempted in 16 patients (median [range] age, 30 [17-76] years; 14 [81%] male; median [IQR] Injury Severity Score, 50 [39-57]). In 2 patients with successful arterial access, REBOA was not attempted due to improvement in clinical condition. In the other 14 patients (8 [57%] of whom were in traumatic cardiac arrest [TCA]), 11 successfully underwent cannulation and had aortic balloons inflated in Z1. The 3 individuals in whom cannulation was unsuccessful were in TCA (failure rate = 3/14 [21%]). Median (IQR) pre-REBOA SBP in the 11 individuals for whom cannulation was successful (5 [46%] in TCA) was 47 (33-52) mm Hg. Z1 REBOA plus P-REBOA was associated with a significant improvement in BP (median [IQR] SBP at emergency department arrival, 101 [77-107] 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 (95% CI, 42-77) mm Hg (P < .004). P-REBOA was feasible in 8 individuals (8/11 [73%]) and occurred spontaneously in 4 of these. The 1- and 3-hour postinjury mortality rate was 9% (1/11), 24-hour mortality was 27% (3/11), and 30-day mortality was 82% (9/11). Survival to hospital discharge was 18% (2/11). Both survivors underwent early Z1 P-REBOA. Conclusions and Relevance: In this study, prehospital Z1 P-REBOA is feasible and may enable early survival, but with a significant incidence of late death. Trial Registration: ClinicalTrials.gov Identifier: NCT04145271.

Frequency of macroscopic intradural hemorrhage with and without subdural hemorrhage in early childhood autopsies.

Some authors have suggested that in the fetus, neonate and infant, intradural hemorrhage (IDH) is relatively common and often presents alongside subdural hemorrhage (SDH). These authors have theorized that pediatric SDH may result from an IDH due to blood leakage from a dural vascular plexus. In this study, we report the inter-observer variation for detection of IDH from a retrospectively collected series of pediatric autopsy photographs, with and without SDH. Autopsy photographs of the falx and tentorium from 27 neonatal, infant and early childhood autopsies were assessed by two independent consultant forensic pathologists blinded to all case histories for the presence and extent (focal or diffuse) of IDH. Inter-observer agreement between the pathologists was calculated using Cohen's kappa coefficient. The occurrence of subdural hemorrhage was also recorded at autopsy. A kappa coefficient value of 0.669 (p = 0.001), indicated a substantial level of agreement for the presence/absence of IDH between the pathologists. For the extent of IDH a kappa coefficient value of 0.6 (p = 0.038) indicated a moderate level of agreement. The pathologists agreed on the presence of IDH in 10 of the 27 cases. Subdural hemorrhage was recorded for 8 out of 27 cases. Of these 8 cases, it was agreed that 4 had IDH. Using standardized methods of image capture and assessment, inter-observer agreement for the presence/absence of IDH was substantial. In this paper, we report a much lower frequency of macroscopic IDH occurring alongside SDH than previous studies, which included both gross observation of IDH and histological examination.

Synchronous ductal carcinoma in situ of the breast and within epithelial inclusions in an ipsilateral sentinel lymph node.

Epithelial inclusions in the axillary lymph nodes are very rare and have even less commonly been reported with either benign or malignant changes. We present a case of synchronous high-grade micropapillary ductal carcinoma in situ arising in the breast and in an epithelial inclusion in an ipsilateral sentinel lymph node. Despite extensive sampling, no focus of invasive carcinoma was identified. This unique case highlights the difficulty in diagnosis of metastatic disease when there is a malignant change in an epithelial inclusion in a sentinel lymph node and highlights the need for very careful histologic assessment of such lesions.

Lung injury similar to blast lung in a case of shotgun wound of the head.

Primary blast lung injury after explosions has been well described in the literature. A case of injury to the lung, after a shotgun wound to the head, similar to primary blast lung, is presented. Histological appearances of the lung revealed alveolar over distension, rupture and intra-alveolar hemorrhage. Primary blast lung injury is considered the reserve of high-order explosives; however, this case reveals similar injuries from a shotgun (low-order explosive), which has not been reported before to the best of our knowledge.