Aortic balloon occlusion in distal zone 3 reduces blood loss from obstetric hemorrhage in placenta accreta spectrum.

BACKGROUND: Peripartum hemorrhage is a significant cause of maternal death. We developed a standardized, multidisciplinary cesarean hysterectomy protocol for placenta accreta spectrum (PAS) using prophylactic resuscitative endovascular balloon occlusion of the aorta (REBOA). We initially placed the balloon in proximal zone 3, below the renal arteries. An internal review revealed more bleeding than expected, and we subsequently changed our protocol to occlude the origin of the inferior mesenteric artery (distal zone 3), to decrease blood flow through collateral circulation. We hypothesized that distal zone 3 occlusion would reduce blood loss and transfusion volume and may permit a longer duration of occlusion compared with proximal zone 3 occlusion without increasing ischemic complications. METHODS: We conducted a single-center retrospective cohort study of patients with suspected PAS who underwent REBOA-assisted cesarean hysterectomy from December 2018 to March 2022. Medical records of all patients with PAS were reviewed. Data were extracted from hospital admission through 3 months postpartum. RESULTS: Forty-four patients met the inclusion criteria. Nine never had the balloon inflated. Eighteen patients had placement in proximal zone 3, whereas twenty-six patients had placement in distal zone 3. Background and clinical characteristics were similar in both groups. Placental pathology was obtained in every case. After adjusting for relevant risk factors, multivariate analysis revealed that distal occlusion was associated with a 45.9% (95% confidence interval, 23.8-61.6%) decrease in estimated blood loss, 41.5% (13.7-60.4%) decrease in red blood cell transfusion volume, and 44.9% (13.5-64.9%) reduction in total transfusion volume. There were no vascular access or resuscitative endovascular balloon occlusion of the aorta-related complications in either group. CONCLUSION: This study highlights the safety of prophylactic REBOA in planned cesarean hysterectomy for PAS and provides a rationale for distal zone 3 positioning to reduce blood loss. Resuscitative endovascular balloon occlusion of the aorta should be considered at other institutions with placenta accreta programs, especially in patients with extensive collateral flow. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

A comparison of two open surgical cricothyroidotomy techniques by military medics using a cadaver model.

STUDY OBJECTIVE: The CricKey is a novel surgical cricothyroidotomy device combining the functions of a tracheal hook, stylet, dilator, and bougie incorporated with a Melker airway cannula. This study compares surgical cricothyroidotomy with standard open surgical versus CricKey technique. METHODS: This was a prospective crossover study using human cadaveric models. Participants included US Army combat medics credentialed at the emergency medical technician-basic level. After a brief anatomy review and demonstration, participants performed in random order standard open surgical cricothyroidotomy and CricKey surgical cricothyroidotomy. The primary outcome was first-pass success, and the secondary outcome measure was procedural time. RESULTS: First-attempt success was 100% (15/15) for CricKey surgical cricothyroidotomy and 66% (10/15) for open surgical cricothyroidotomy (odds ratio 16.0; 95% confidence interval 0.8 to 326). Surgical cricothyroidotomy insertion was faster for CricKey than open technique (34 versus 65 seconds; median time difference 28 seconds; 95% confidence interval 16 to 48 seconds). CONCLUSION: Compared with the standard open surgical cricothyroidotomy technique, military medics demonstrated faster insertion with the CricKey. First-pass success was not significantly different between the techniques.

An analysis of battlefield cricothyrotomy in Iraq and Afghanistan.

OBJECTIVE: Historical review of modern military conflicts suggests that airway compromise accounts for 1?2% of total combat fatalities. This study examines the specific intervention of pre-hospital cricothyrotomy (PC) in the military setting using the largest studies of civilian medics performing PC as historical controls. The goal of this paper is to help define optimal airway management strategies, tools and techniques for use in the military pre-hospital setting. METHODS: This retrospective chart review examined all patients presenting to combat support hospitals following prehospital cricothyrotomy during combat operations in Iraq and Afghanistan during a 22-month period. A PC was determined ?successful? if it was documented as functional on arrival to the hospital. All PC complications that were documented in the patients? record were also noted in the review. RESULTS: Two thirds of the patients died. The most common injuries were caused by explosions, followed by gunshot wounds (GSW) and blunt trauma. Eighty-two percent of the casualties had injures to face, neck or head. Those injured by gunshot wounds to the head or thorax all died. The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Pre-hospital cricothyrotomy was documented as successful in 68% of the cases while 26% of the PC?s failed to cannulate the trachea. In 6% of cases the patient was pronounced dead on arrival without documentation of PC function. The majority of PC?s (62%) were performed by combat medics at the point of injury. Physicians and physician assistants (PA) were more successful performing PC than medics with a 15% versus a 33% failure rate. Complications were not significantly different than those found in civilian PC studies, including incorrect anatomic placement, excessive bleeding, air leak and right main stem placement. CONCLUSIONS: The majority of patients who underwent PC died (66%). The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Military medics have a 33% failure rate when performing this procedure compared to 15% for physicians and physician assistants. Minor complications occurred in 21% of cases. The survival rate and complication rates are similar to previous civilian studies of medics performing PC. However the failure rate for military medics is three to five times higher than comparable civilian studies. Further study is required to define the optimal equipment, technique, and training required for combat medics to master this infrequently performed but lifesaving procedure.

Advanced airway management in combat casualties by medics at the point of injury: a sub-group analysis of the reach study.

UNLABELLED: background: Optimal airway management protocols for the prehospital battlefield setting have not been defined. Airway management strategies in this environment must take into account the injury patterns, the environment and training requirements of military prehospital providers. METHODS: This is a post-hoc, sub-group analysis of the Registry of Emergency Airways Arriving at Combat Hospitals or REACH database. This study examines only those patients who had advanced airways placed for trauma by an enlisted military medic at the point of injury. results: Twenty (100%) of the patients had a traumatic injury, 19 (95%) were male, and 13 (65%) had a gun shot wounds (GSWs) as the mechanism of injury. The majority, 12 (60%) patients had an esophageal-tracheal airway device placed. Of the remaining patients, four (20%) underwent endotracheal intubation, three (15%) had a surgical cricothyroidotomy performed, and one (5%) had a Laryngeal Mask Airway (LMA) placed. Seventeen (85%) of the twenty patients were dead on arrival or died shortly after arrival at the Combat Support Hospital (CSH). All of the patients that died had a Glasgow Coma Scale (GCS) of three upon arrival. The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. Three patients in this group survived to transfer from the CSH. Two of the transfers were lost to follow up, one with a GSW to the head and GCS of three, the other with a GCS of five from injuries sustained in an explosion. The third patient had a surgical cricothyroidotomy (SC) performed in the field for an expanding neck hematoma and recovered fully following surgery. conclusions: Casualties that tolerate invasive airway management without sedation in the context of trauma prognosticates a very high mortality. Airway management algorithms for military providers should reflect the casualties encountered on the battlefield not patients in cardiac arrest which predominate in the civilian EMS airway management practice. Further data are needed to understand the injuries encountered on the battlefield and to develop airway management solutions that optimize outcomes of patients with battlefield trauma.