Main text
aortic occlusion, bleeding, head injury, Traumatic brain injury, cardiac arrest, haemorrhage, trauma
AORTIC OCCLUSION, BLEEDING, STILL, CARDIAC ARREST, HAEMORRHAGE, HAEMORRHAGIC SHOCK
The UK-REBOA trial aimed to investigate patients suffering haemorrhagic shock and randomized to standard care alone (SC) or REBOA as adjunct to standard care. The study (and subsequently commentators on social media platforms such as Twitter/X) concludes that REBOA may increase the mortality [The study leaves numerous points to discuss and to cut it short, we do not necessarily agree with the study’s conclusion.Just 90 out of the intended 120 patients were included, with 44 patients in the SC group and 46 in the REBOA group. Randomization is a means to obtain matching study groups, but given that the trial was stopped early, the groups may not actually be comparable. A sensitivity analysis was performed to adjust for differences, without significant effects. Still, there are some striking differences between the groups that may not have been included into the analysis.All patients were critically injured, with a median injury severity score of 41. Twenty-three percent of the patients were in cardiac arrest at some point, demonstrating the severity of the situation and realistically poor prognosis, as cardiac arrest following trauma has devastatingly low survival [The abbreviated injury scales in the groups were similar, except for head injury where the REBOA group scored higher. Traumatic brain injury itself is associated with mortality [Only 19 (41%) patients received aortic occlusion in the REBOA group and arterial access failed in 8 (17%) patients. Two (5%) patients in the SC group received REBOA, without explanation for the cross-over. Hence, this is a very low number for a strong worded conclusion.However, this is not the most concerning finding. It’s the matter of minutes. We recognise that this is not the authors fault, but more a systematic health care limitation. Prehospital times were long, with a median of 90 min from injury to hospital arrival. As prehospital physicians, we understand that prehospital time may be prolonged due to weather, difficulties to extract trauma patients etc., but 90 min from injury to admission, without haemorrhage control, will surely influence outcome. The time from randomization in the emergency room to ‘definitive haemorrhagic controlling procedure’ was 64 min in the SC and 83 min in the REBOA group. The interquartile range in the REBOA group was 56 to concerning 156 min. This leaves the patient with hours of bleeding prior to being subject to a haemorrhage controlling procedure. Such time expenditure is neither the study nor the REBOA procedure’s fault, but a characteristic of the health care system investigated.Further, 32 min to perform REBOA is a surprisingly high procedure time, considered this is performed in the emergency room with adequate ambient lighting and temperature, multiple available personnel and equipment. In the setting of out-of-hospital cardiac arrest, REBOARREST trial participants use approximately 12 min on the REBOA procedure (one physician and one paramedic) [