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30/09/2015

REBOA: Un savoir faire à maîtriser ?

Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage

Moor LJ et Al.  J Trauma Acute Care Surg. 2015;79: 523-532

 

L'application du concept du garrot tactique a fait évoluer la répartition des causes évitables de décès à l'avant et met actuellement au premier plan les hémorragies du tronc (Eastridge) . SI le bon usage du garrot reste un enjeu essentiel, les efforts portent maintenant sur la prise en charge d'une part des hémorragies jonctionnelles avec le recours de dispositifs tels que le CRoC, le Sam Junctional tourniquet ou l'abdominal tourniquet et d'autre part sur la prise en charge des hémorragies du tronc. Une autre approche, connue depuis de nombreuses années mais tombée en désuétude, refait surface. L'occlusion endovasculaire de l'aorte abdominale apparaît être d'un intérêt certain. C'est ce que documente le travail présenté ci dessous. Réaliser un tel geste en préhospitalier est possible (1,2). En ce qui concerne les applications militaires dans les structures chirurgicales de role 2 voire dans certaines moyens de transport préhospitalier une réflexion apparaît nécessaire. 

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BACKGROUND:

Hemorrhage remains the leading cause of death in trauma patients. Proximal aortic occlusion, usually performed by direct aortic cross-clamping via thoracotomy, can provide temporary hemodynamic stability, permitting definitive injury repair. Resuscitative endovascular balloon occlusion of the aorta (REBOA) uses a minimally invasive, transfemoral balloon catheter, which is rapidly inserted retrograde and inflated for aortic occlusion, and may control inflow and allow time for hemostasis. We compared resuscitative thoracotomy with aortic cross-clamping (RT) with REBOA in trauma patients in profound hemorrhagic shock.

METHODS: Trauma registry data was used to compare all patients undergoing RTor REBOA during an 18-month period from two Level 1 trauma centers.

RESULTS: There was no difference between RT (n = 72) and REBOA groups (n = 24) in terms of demographics, mechanism of injury, or Injury Severity Scores (ISSs). There was no difference in chest and abdominal Abbreviated Injury Scale (AIS) scores between the groups. However, the RT patients had lower extremity AIS score as compared with REBOA patients (1.5 [0-3] vs. 4 [3-4],p G 0.001). Of the 72 RT patients, 45 (62.5%) died in the emergency department, 6 (8.3%) died in the operating room, and 14 (19.4%) died in the intensive care unit. Of the 24 REBOA patients, 4 (16.6%) died in the emergency department, 3 (12.5%) died in the operating room, and 8 (33.3%) died in the intensive care unit. In comparing location of death between the RT and REBOA groups, there were a significantly higher number of deaths in the emergency department among the RT patients as compared with the REBOA patients (62.5% vs. 16.7%, p G 0.001). REBOA had fewer early deaths and improved overall survival as compared with RT (37.5% vs. 9.7%, p = 0.003).

 CONCLUSION: REBOA is feasible and controls noncompressible truncal hemorrhage in trauma patients in profound shock. Patients undergoing REBOA have improved overall survival and fewer early deaths as compared with patients undergoing RT. 

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