Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Severe Torso Trauma in Japan: A Descriptive Study.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to be an alternative to open aortic cross-clamping (ACC). However, its practical indication remains unknown. We examined the usage trend of REBOA and ACC in Japan for severe torso trauma and investigated whether these procedures were associated with the time of death distribution based on a large database from the Japan Trauma Data Bank (JTDB). METHODS: The JTDB from 2004 to 2014 was reviewed. Eligible patients were restricted to those with severe torso trauma, which was defined as an abbreviated injury scale score of ≥4. Patients were classified into groups according to the aortic occlusion procedures. The primary outcomes were the rates of REBOA and ACC use according to the clinical situation. We also evaluated whether the time of death distribution for the first 8 h differed based on these procedures. RESULTS: During the study period, a total of 21,533 patients met our inclusion criteria. Overall, REBOA was more commonly used than ACC for patients with severe torso trauma (2.8% vs 1.5%). However, ACC was more frequently used in cases of thoracic injury and cardiac arrest. Regarding the time of death distribution, the cumulative curve for death in REBOA cases was elevated much more slowly and mostly flat for the first 100 min. CONCLUSIONS: REBOA is more commonly used compared to ACC for patients with severe torso trauma in Japan. Moreover, it appears that REBOA influences the time of death distribution in the hyperacute phase.

Transcatheter Arterial Embolization in the Treatment of Maxillofacial Fractures With Life-Threatening Hemorrhage.

INTRODUCTION: Transcatheter arterial embolization (TAE) has gained importance in the management of maxillofacial fractures with life-threating hemorrhage (MFH). However, clinical evidence supporting the use of TAE has not been clearly established in the literature. Therefore, we evaluated the effectiveness of TAE for MFH, based on data obtained from the Japan Trauma Data Bank. METHODS: Patients were identified from Japan Trauma Data Bank entries for the years 2004 to 2014. Inclusion criteria for MFH were defined using the Abbreviated Injury Scale code (Maxilla fracture, LeFort III; blood loss. > 20%). On the basis of the treatment strategy, patients were categorized into either the TAE group or the non-TAE group. A comparative analysis of the demographics, injury characteristics, and outcomes was performed. RESULTS: From among 198,744 documented cases of trauma, a total 118 patients were eligible for the study; 26 of these patients (22.0%) underwent TAE. The Glasgow Coma Scale score was significantly lower in the TAE group than in the non-TAE group (P = 0.019); the other variables did not significantly differ between the groups. Overall, the in-hospital mortality rate was 39.8%, and the median hospital length of stay was 21.0 days (0.0-53.5 days). The in-hospital mortality was significantly lower in the TAE group than in the non-TAE group (23.1% vs 44.6%; odds ratio [OR], 0.37; 95% confidence interval [CI], 0.14-1.02; p = 0.048). However, patients in the TAE group had a longer median hospital length of stay (39.5 [7.3-53.5] vs 14.0 [0.0-55.3] days, p = 0.072). In the logistic regression model, the use of TAE was extracted as the independent predictor for better outcomes after adjusting for potential confounders (OR, 0.32; 95% CI, 0.66-0.88; P = 0.032). Hypotension, a high Injury Severity Score, aged 60 years or older, and a low Glasgow Coma Scale score were also independently associated with mortality, with an OR of 5.48, 3.99, 3.30, and 2.89, respectively. CONCLUSIONS: Cases of MFH are rare, but they are associated with a high mortality. Transcatheter arterial embolization use appears to lead to successful outcomes in such cases. Further studies are required to confirm the efficacy of TAE and evaluate its indications and complications.

Clinical Evaluation of "Shock Bowel" Using Intestinal Fatty Acid Binding Protein.

"Shock bowel" is one of the computed tomographic (CT) signs of hypotension, yet its clinical implications remain poorly understood. We evaluated how shock bowel affects clinical outcomes and the extent of intestinal epithelial damage in trauma patients by measuring the level of intestinal fatty acid binding protein (I-FABP). We reviewed the initial CT scans, taken in the emergency room, of 92 patients with severe blunt torso trauma who were consecutively admitted during a 24-month period. The data collected included CT signs of hypotension, I-FABP, feeding intolerance, and other clinical outcomes. Demographic and clinical outcomes were compared in patients with and without hemodynamic shock and shock bowel. Shock bowel was found in 16 patients (17.4%); of them 7 patients (43.8%) did not have hemodynamic shock. Certain CT signs of hypotension, namely free peritoneal fluid, contrast extravasation, small-caliber aorta, and shock bowel, were significantly more common in patients with hemodynamic shock than in patients without (P < 0.05). Injury severity score and the rate of consciousness disturbance were significantly higher in patients with shock bowel than in patients without (P < 0.05). The rate of feeding intolerance and median plasma I-FABP levels were significantly higher in patients with shock bowel than in patients without (75.0% vs. 22.4%, P < 0.001 and 17.0 ng/mL vs. 3.7 ng/mL, P < 0.001, respectively). There was no difference in mortality. In conclusion, shock bowel is not always due to hemodynamic shock. It does, however, indicate severe intestinal mucosal damages and may predict feeding intolerance.