Zones matter: Hemodynamic effects of zone 1 vs zone 3 resuscitative endovascular balloon occlusion of the aorta placement in trauma patients

Carl A. Beyer, Michael Johnson, Joseph M Galante, Joseph J. DuBose

Research output: Contribution to journalArticle

Abstract

Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a therapy for hemorrhagic shock to limit ongoing bleeding and support proximal arterial pressures. Current REBOA algorithms recommend zone selection based on suspected anatomic location of injury rather than severity of shock. We examined the effects of Zone 1 versus Zone 3 REBOA in patients enrolled in the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry. Patients and methods: The prospective observational AORTA Registry was queried from November 2013 to November 2017. Patients who received REBOA were included if their initial systolic blood pressure (SBP) was less than 90 mmHg upon arrival and they were not receiving cardiopulmonary resuscitation. Results: There were 762 patients recorded in the AORTA database during the study period. Of these, 245 underwent REBOA and 99 patients met inclusion criteria. The initial balloon position was Zone 1 in 55 patients, Zone 3 in 36 patients, and unknown or Zone 2 in 8 patients. The change in proximal SBP was greater after REBOA in the Zone 1 group compared to the Zone 3 group (58 ± 4 mmHg vs 41 ± 4 mmHg, P = 0.008). The zone of occlusion was significantly associated with the change in proximal SBP in a linear regression analysis which included initial SBP, Glasgow Coma Scale score, and Injury Severity Score (Coefficient 26.82, 95% Confidence Interval 8.11–45.54, P = 0.006). Conclusions: In the hypotensive trauma patient, initial Zone 1 REBOA provides maximal hemodynamic support. Algorithms recommending initial Zone 3 placement for hypotensive trauma patients should be reconsidered.

Original languageEnglish (US)
JournalInjury
DOIs
StatePublished - Jan 1 2019

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Balloon Occlusion
Aorta
Hemodynamics
Wounds and Injuries
Blood Pressure
Registries
Glasgow Coma Scale
Injury Severity Score
Hemorrhagic Shock
Cardiopulmonary Resuscitation
Resuscitation
Linear Models
Shock
Arterial Pressure
Regression Analysis
Databases
Confidence Intervals
Hemorrhage

Keywords

  • Aortic occlusion
  • Endovascular therapy
  • Hemorrhagic shock
  • REBOA
  • Resuscitation

ASJC Scopus subject areas

  • Emergency Medicine
  • Orthopedics and Sports Medicine

Cite this

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title = "Zones matter: Hemodynamic effects of zone 1 vs zone 3 resuscitative endovascular balloon occlusion of the aorta placement in trauma patients",
abstract = "Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a therapy for hemorrhagic shock to limit ongoing bleeding and support proximal arterial pressures. Current REBOA algorithms recommend zone selection based on suspected anatomic location of injury rather than severity of shock. We examined the effects of Zone 1 versus Zone 3 REBOA in patients enrolled in the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry. Patients and methods: The prospective observational AORTA Registry was queried from November 2013 to November 2017. Patients who received REBOA were included if their initial systolic blood pressure (SBP) was less than 90 mmHg upon arrival and they were not receiving cardiopulmonary resuscitation. Results: There were 762 patients recorded in the AORTA database during the study period. Of these, 245 underwent REBOA and 99 patients met inclusion criteria. The initial balloon position was Zone 1 in 55 patients, Zone 3 in 36 patients, and unknown or Zone 2 in 8 patients. The change in proximal SBP was greater after REBOA in the Zone 1 group compared to the Zone 3 group (58 ± 4 mmHg vs 41 ± 4 mmHg, P = 0.008). The zone of occlusion was significantly associated with the change in proximal SBP in a linear regression analysis which included initial SBP, Glasgow Coma Scale score, and Injury Severity Score (Coefficient 26.82, 95{\%} Confidence Interval 8.11–45.54, P = 0.006). Conclusions: In the hypotensive trauma patient, initial Zone 1 REBOA provides maximal hemodynamic support. Algorithms recommending initial Zone 3 placement for hypotensive trauma patients should be reconsidered.",
keywords = "Aortic occlusion, Endovascular therapy, Hemorrhagic shock, REBOA, Resuscitation",
author = "Beyer, {Carl A.} and Michael Johnson and Galante, {Joseph M} and DuBose, {Joseph J.}",
year = "2019",
month = "1",
day = "1",
doi = "10.1016/j.injury.2019.03.013",
language = "English (US)",
journal = "Injury",
issn = "0020-1383",
publisher = "Elsevier Limited",

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T1 - Zones matter

T2 - Hemodynamic effects of zone 1 vs zone 3 resuscitative endovascular balloon occlusion of the aorta placement in trauma patients

AU - Beyer, Carl A.

AU - Johnson, Michael

AU - Galante, Joseph M

AU - DuBose, Joseph J.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a therapy for hemorrhagic shock to limit ongoing bleeding and support proximal arterial pressures. Current REBOA algorithms recommend zone selection based on suspected anatomic location of injury rather than severity of shock. We examined the effects of Zone 1 versus Zone 3 REBOA in patients enrolled in the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry. Patients and methods: The prospective observational AORTA Registry was queried from November 2013 to November 2017. Patients who received REBOA were included if their initial systolic blood pressure (SBP) was less than 90 mmHg upon arrival and they were not receiving cardiopulmonary resuscitation. Results: There were 762 patients recorded in the AORTA database during the study period. Of these, 245 underwent REBOA and 99 patients met inclusion criteria. The initial balloon position was Zone 1 in 55 patients, Zone 3 in 36 patients, and unknown or Zone 2 in 8 patients. The change in proximal SBP was greater after REBOA in the Zone 1 group compared to the Zone 3 group (58 ± 4 mmHg vs 41 ± 4 mmHg, P = 0.008). The zone of occlusion was significantly associated with the change in proximal SBP in a linear regression analysis which included initial SBP, Glasgow Coma Scale score, and Injury Severity Score (Coefficient 26.82, 95% Confidence Interval 8.11–45.54, P = 0.006). Conclusions: In the hypotensive trauma patient, initial Zone 1 REBOA provides maximal hemodynamic support. Algorithms recommending initial Zone 3 placement for hypotensive trauma patients should be reconsidered.

AB - Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a therapy for hemorrhagic shock to limit ongoing bleeding and support proximal arterial pressures. Current REBOA algorithms recommend zone selection based on suspected anatomic location of injury rather than severity of shock. We examined the effects of Zone 1 versus Zone 3 REBOA in patients enrolled in the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry. Patients and methods: The prospective observational AORTA Registry was queried from November 2013 to November 2017. Patients who received REBOA were included if their initial systolic blood pressure (SBP) was less than 90 mmHg upon arrival and they were not receiving cardiopulmonary resuscitation. Results: There were 762 patients recorded in the AORTA database during the study period. Of these, 245 underwent REBOA and 99 patients met inclusion criteria. The initial balloon position was Zone 1 in 55 patients, Zone 3 in 36 patients, and unknown or Zone 2 in 8 patients. The change in proximal SBP was greater after REBOA in the Zone 1 group compared to the Zone 3 group (58 ± 4 mmHg vs 41 ± 4 mmHg, P = 0.008). The zone of occlusion was significantly associated with the change in proximal SBP in a linear regression analysis which included initial SBP, Glasgow Coma Scale score, and Injury Severity Score (Coefficient 26.82, 95% Confidence Interval 8.11–45.54, P = 0.006). Conclusions: In the hypotensive trauma patient, initial Zone 1 REBOA provides maximal hemodynamic support. Algorithms recommending initial Zone 3 placement for hypotensive trauma patients should be reconsidered.

KW - Aortic occlusion

KW - Endovascular therapy

KW - Hemorrhagic shock

KW - REBOA

KW - Resuscitation

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