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• W2951482967 abstract "We are grateful for the interest in our work by Thabouillot et al. and welcome the opportunity to respond to the points raised. We agree with the authors premise regarding the need to accurately define which patients may or may not benefit from interventions like REBOA and in which context (pre-hospital, in-hospital, operating room) it is most effective. As our global understanding evolves, we recognise the importance of careful investigations such as the ongoing, multicentre UK-REBOA Trial, at informing our practice.1Jansen J.O. Pallmann P. Maclennan G. Campbell M.K. Bayesian clinical trial designs: another option for trauma trials?.J Trauma Acute Care Surg. 2017; 4: 736-741https://doi.org/10.1097/TA.0000000000001638Crossref Scopus (16) Google Scholar Currently, our indications for pre-hospital Zone III REBOA are adults with non-compressible exsanguinating haemorrhage from either blunt or penetrating pelvic injury, who are assessed to be at imminent risk of hypovolaemic cardiac arrest.2Lendrum R. Perkins Z. Chana M. et al.Pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) for exsanguinating pelvic haemorrhage.Resuscitation. 2018; 135: 6-13https://doi.org/10.1016/j.resuscitation.2018.12.018Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Our service specifically avoids relying on pre-defined thresholds of systolic blood pressure or treatment criteria such as inotrope administration as described by Thabouillot et al., in critical decision-making. In our experience, no clinical factor in isolation can reliably assist clinicians predict which injured patients are at imminent risk of exsanguination and pre-hospital cardiac arrest, and which would survive to hospital and definitive haemostasis. We regularly encounter patients with profound hypotension very soon after injury that is unrelated to haemorrhage and caused by fundamentally different pathophysiological mechanisms, such as impact brain apnoea, cardiogenic shock post head injury or vagal response to pain.3Wilson M.H. Hinds J. Grier G. Burns B. Carley S. Davies G. Impact brain apnoea — A forgotten cause of cardiovascular collapse in trauma.Resuscitation. 2016; 105: 52-58https://doi.org/10.1016/j.resuscitation.2016.05.007Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Therefore, we believe it is paramount to make a clinical diagnosis of exsanguinating haemorrhage, rather than depend on blood pressure measurements alone, when establishing indication criteria for REBOA. The following criteria are used to identify patients with exsanguinating haemorrhage in our pre-hospital service. They are based on our institutional experience and the available clinical and physiological research on the human response to haemorrhage following injury.4Little R.A. Kirkman E. Driscoll P. Hanson J. Mackway-Jones K. Preventable deaths after injury: why are the traditional “vital” signs poor indicators of blood loss?.J Accid Emerg Med. 1995; 12: 1-14Crossref PubMed Scopus (47) Google Scholar, 5Kirkman E. Watts S. Haemodynamic changes in trauma.Br J Anaesth. 2014; 113: 266-275https://doi.org/10.1093/bja/aeu232Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Diagnosis of exsanguinating pelvic haemorrhage:•Mechanism associated with large energy transfer or a penetrating injury to the pelvis.•Injuries compatible with vascular disruption and exsanguinating haemorrhage.•Appropriate time course (rapid evolution of shocked state).•The following clinical signs (“Hateful Eight”)1Pale2Clammy3“Air-hunger”4Venous collapse5Hypotension (low volume or absent peripheral pulses)6Low/falling ETCO27Tachy or bradycardia8Altered mentation We feel this is approach is pragmatic. However, we acknowledge the need for high quality future research to (a) better define the patient groups that derive benefit from REBOA, and (b) develop novel diagnostic and decision-support tools that enhance treatment decisions. The rationale behind the use of REBOA in Zone III alone is described in our paper.2Lendrum R. Perkins Z. Chana M. et al.Pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) for exsanguinating pelvic haemorrhage.Resuscitation. 2018; 135: 6-13https://doi.org/10.1016/j.resuscitation.2018.12.018Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Excluding coexistent abdominal haemorrhage in patients undergoing Zone III REBOA is challenging and it is impossible to “rule-out” more proximal haemorrhage with or without Focused Assessment Sonography in Trauma (FAST). Therefore, making a clinical diagnosis as to the most likely source of haemorrhage based on detailed assessment of the mechanism of injury and meticulous clinical examination remains fundamental. Furthermore, although Zone III REBOA may aggravate more proximal sites of bleeding, we don’t believe that this is a contra-indication to its use in patients assessed to be at imminent risk of cardiovascular collapse from exsanguinating pelvic haemorrhage. Dr Robbie Lendrum is a National Institute for Health Research, Health Technology Assessment (NIHR HTA) grant holder for the UK-REBOA Trial. No other disclosures were reported. Prehospital REBOA: Time to clearly define the relevant indicationsResuscitationVol. 142PreviewWe read with great interest the recently published study by Lendrum et al. on the first case series of civilian prehospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for exsanguinating pelvic haemorrhage.1 Although these results seem promising, we raise some concerns regarding the following points. Full-Text PDF" @default.
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• W2951482967 title "Reply to: Prehospital REBOA: Time to clearly define the relevant indications" @default.
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