Hong Kong Journal of Emergency Medicine

Resuscitative endovascular balloon occlusion of the aorta is used as adjunctive management for a profound shock in some trauma centers. We report our early experience of resuscitative endovascular balloon occlusion of the aorta to describe the implementation and possible indications of resuscitative endovascular balloon occlusion of the aorta.

This study was designed to investigate the feasibility and effectiveness of resuscitative endovascular balloon occlusion of the aorta based on our experience and share our implementation process by trauma surgeons in Korea.

We performed a retrospective review of consecutive cases of resuscitative endovascular balloon occlusion of the aorta in profound shock due to noncompressible torso hemorrhage at a single Korean trauma center. Resuscitative endovascular balloon occlusion of the aorta was introduced and implemented with written protocol and endovascular training courses.

All cases (n = 24) were done for blunt mechanisms. Twelve cases (50%) were resuscitative endovascular balloon occlusion of the aorta in zone I, three cases (12.5%) were zone II, and nine cases (45%) in zone III. Mean pre-occlusion systolic blood pressure was 47 mm Hg and mean systolic blood pressure increase was 41.3 mm Hg. Twenty-one patients (87.5%) survived at trauma bay and seven patients (29.2%) survived and discharged without neurologic deficit. There were two complications directly related to the procedure.

Resuscitative endovascular balloon occlusion of the aorta is a useful adjunctive skill for trauma surgeons, and a brief training course can help in the implementation of the procedure.

Pelvic fracture causes significant mortality and morbidities. The purpose of this study is to identify the characteristics of patients with pelvic fracture in Hong Kong and to determine the factors predicting mortality. The result could help to identify high-risk patients who might benefit from more intensive evaluation and intervention.

Five hundred and eight patients (age > 12 years old) with pelvic fractures were identified from the trauma registries of four designated trauma centres in Hong Kong from 1 January 2005 to 31 December 2012. Patient baseline characteristics and outcomes were analysed. Stepwise logistic regression was performed to identify independent clinical predictors for mortality.

Mean age was 45.4 ± 19.2 years, 43.3% were female, mean length of hospital stay was 27.9 ± 42.4 days and mean length of intensive care unit stay was 4.8 ± 6.8 days. Injury severity score was 28.9 ± 18.7, revised trauma score was 7.2 ± 2 and 30-day mortality was 20.9%. Stepwise logistic regression identified patient’s age, presenting systolic blood pressure, initial Glasgow Coma Scale, injuries to the thoracic and abdominal regions, first base excess and the volume of red blood cell transfusion required within the first 6 h to be independent risk factors predicting mortality.

Pelvic fracture is associated with significant risk of mortality in major trauma patients. Clinical characteristics obtained during emergency department resuscitation can help in selecting patients for timely aggressive interventions.

While there are intrinsic differences in the pros and cons between plain radiographs and computer tomography, the role of pelvic radiographs in polytrauma management is diminishing as computer tomography scans are becoming more accessible. Previous studies found varying results in the inter-observer agreement in pelvic radiograph interpretations.

To evaluate inter-observer agreement of classifying pelvic fractures in major trauma patients by emergency physicians, and the inter-method agreement between plain radiographs and computer tomography scans.

Three hundred sixty-nine patients with pelvic trauma were recruited from the trauma registries of four designated trauma centres in Hong Kong, each having one set of anteroposterior pelvic radiographs and pelvic computer tomography scans. Pelvic radiographs were classified by two emergency physicians using Young–Burgess classification, and pelvic computer tomography scans classified by an experienced radiologist. Disagreed pelvic radiographs were evaluated by a senior emergency physician to make a final decision before comparing with computer tomography scans. Cohen’s kappa was used to measure the inter-observer and the inter-method agreements, in the groups ‘mechanism of injury’, ‘stable versus unstable fractures’ and ‘complete classification’.

Inter-observer agreements of plain radiograph classification for ‘mechanism of injury’, ‘stable versus unstable fractures’ and ‘complete classification’ were moderate to substantial (κ = 0.72, 0.60 and 0.55, respectively). Inter-method agreement for the three groups between plain radiographs and computer tomography were fair to moderate (κ = 0.42, 0.59 and 0.38, respectively).

The inter-method agreement between plain pelvic radiographs and computer tomography scans was fair in classifying pelvic fractures, and moderate in detection of unstable pelvic fractures. If the patient is haemodynamically unstable or when computer tomography is unavailable, it is reasonable to obtain plain radiographs to screen for unstable pelvic fractures to expedite early intervention. A review in the education approach and material of Young–Burgess classification may improve inter-observer agreement.

Generally, in traumatic patients, uncontrolled bleeding leads to shock and ultimately death. So, any early detection of shock can reduce the likelihood of a patient’s death. At present, the precise method for estimating the body’s need for fluids is to measure central venous pressure (CVP). However, this method is invasive and time consuming.

This study aimed to predict the central venous pressure value and range of trauma patients through non-invasive parameters such as caval index, lactate clearance, base excess and shock index.

A prospective observational study was performed in 100 trauma patients. Written informed consent was obtained from patient(s) or relatives for their anonymized information to be published in any article.

It indicated that parameters such as caval index (at a proposed cutoff point of 35%), lactate clearance (at a cutoff point of 6%) and base excess (at a proposed cutoff point of 6 mmol/L) are approximately of the same level of accuracy for estimating the central venous pressure range, while parameter shock index (at a cutoff point of 1.25) is of the least level of accuracy to predict the central venous pressure range. Results also showed that among all proposed predictive models for estimating the central venous pressure value, which were on the basis of either non-linear regression or artificial neural network, the most accurate model was the one on the basis of the artificial neural network. Among parameters lactate clearance, base excess and shock index used to form the artificial neural network-based model, parameters base excess and lactate clearance were of the highest and lowest level of importance, respectively.

Among all proposed models and non-invasive parameters to predict the central venous pressure range, CVP_LC model (at a cutoff point of 9), which is a non-linear regression model and is in terms of parameter lactate clearance, was the most accurate model.

Hemorrhage is the leading cause of death in trauma settings. Non-compressible torso hemorrhage, which is caused by abdominopelvic and thoracic injuries, is an important cause of subsequent organ dysfunction and poor outcomes in multiple trauma patients. The management of hemodynamically unstable patients with non-compressible torso hemorrhage has changed, and the concept of damage control resuscitation has been developed in the last decades. Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) as a method of temporary stabilization is the modern evolution of bleeding control, and it is in the middle of a paradigm shift as a treatment for non-compressible torso hemorrhage. Despite its effectiveness in patients with hemorrhagic shock, the application of REBOA remains limited because of lack of experience and troubleshooting guidelines.

The aim of study was to provide useful tips for the implementing a step-by-step procedure for REBOA in various hospital settings and capabilities.

We introduced REBOA procedures using a REBOA-customized 7 Fr balloon catheter through the animation models or radiography from preparation to access, catheter management, and device removal after procedure completed.

We have described REBOA procedures as follows: identification of the common femoral artery, arterial access for placement of a guidewire, precautions during a sheath insertion, guidewire and balloon positioning in the aorta, occlusion zones and adjustment of balloon location, REBOA strategy for extending the occlusion time, balloon deflation and removal, sheath removal, and medical records.

We believe that the practical tips mentioned in this article will help in performing the REBOA procedure systematically and developing an effective REBOA framework.

Globally, terrorist attacks have major impact because of high rates of mortality and severe injury. Compression with direct pressure may be time-consuming in limb exsanguination and accelerate onset of haemorrhagic shock. Tourniquet applications have undergone scrutiny over a long period, but recently tourniquets have been developed and modified for effective and efficient use in prehospital settings to mitigate adverse effects.

This systematic review aimed at examining commercial tourniquets that demonstrated efficacy for use in prehospital services.

Six search engines (ScienceDirect, Ovid, PubMed, SAGE, SpringerLink, Taylor & Francis) were used and articles of which 14 were selected for data analysis.

The findings were not sufficiently conclusive to pinpoint whether one tourniquet application was superior overall; however, Combat Application Tourniquet appeared to be better than other commercial tourniquets in terms of occlusion of distal blood flow, easy and quick self-application and fewer complications.

In prehospital settings, ambulance personnel should not hesitate to apply tourniquets when encountering critical circumstances in which they must choose between saving life and potential complications.

Transorbital low-velocity penetrating head injuries are uncommon but important. Minor skin wounds may herald intracranial injury with high morbidity and mortality.

A fencing coach was pierced by a sabre between his nose and right eye resulting in orbital roof fracture and frontal lobe laceration. With prompt recognition of these injuries under multidisciplinary management, he attained uncomplicated recovery.

The emergency physician should maintain a high index of suspicion for intracranial injury in patients presenting with history of penetrating head injury. Understanding orbital anatomy, injury mechanisms and patterns can facilitate timely management to prevent potentially sight-threatening and life-threatening complications.