➡️ REBOA is an exciting "new" therapy for non-compressible torso haemorrhage
➡️ It's used across the world, but without robust evidence
➡️ Does it work? Is it beneficial?
➡️ A thread...
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🚩 Uncontrollable haemorrhage accounts for
➡️ > 80% of combat deaths
➡️ ~ 40% of civilian trauma-related deaths
🚩 Many have been determined to be preventable deaths
🚩 ~ 67% of fatal bleeding occurs in the torso region
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Emergency thoracotomy (ET) has a long history in resuscitation
🚩 1880 - Paul Niehans first documented ET in human cardiac arrest
🚩 1901 - Kristian Ingelsrud performed the first successful resuscitation
🚩 1953 - Stephenson had 28% survival in 1200 cardiac arrests
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🚩 1960s - the twin developments of closed chest cardiac massage & defibrillation lead to a decline in ET for cardiac arrest
🚩 But closed chest compressions were ineffective for trauma
🚩 1967 - Beall reported the re-use of ET for resuscitation, renewing interest in ET
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🚩 REBOA was first described by American Lt. Col. Carl W. Hughes in 1954 during the Korean War
🚩 Aortic occlusion was with a Dotter-Lukas balloon
🚩 2 patients were treated & died, from multiple GSWs & grenade blast injuries
🚩 Hughes felt survival had been possible
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🚩 REBOA indications
1⃣ traumatic life-threatening hemorrhage below the diaphragm in hemorrhagic shock patients unresponsive or transiently responsive to resuscitation
2⃣ patients in arrest from injury due to presumed life-threatening hemorrhage below the diaphragm
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🚩 Procedure
REBOA is inserted using a Seldinger technique, either via
1⃣ surgical cut-down
2⃣ percutaneously with ultrasound
🔴 It is left in place for as short a time as possible
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🚩 REBOA is placed in either zone 1 or 3
1⃣ Zone 1 - for any hemorrhages originating below the diaphragm & patients in cardiac arrest
2⃣ Zone 3 - for pelvic injuries with no evidence of intraabdominal bleeding
Zone 2 occludes visceral arteries and is rarely chosen
🔴 AORTA 1 study
➡️ Mortality (REBOA v Thoracotomy) 72% vs. 84%; P = 0.12
🟠 AORTA 2
➡️ Mortality 48% v. 93%, P <0.001 (if no CPR)
🟡 Japan Trauma Data Bank (2023)
➡️ Mortality 55.2% v 81.6%; P < 0.001
➡️ Antimicrobial therapy has been used for millennia
➡️ Treating severe infections can be lifesaving
➡️ However, the widespread use of antimicrobials also has downsides
A 🧵
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➡️ Throughout history, honey, herbs & metals were often used
➡️ One of the earliest known antimicrobial therapies was the topical use of mouldy bread
➡️ This intervention has been recorded in many ancient civilisations, including Egypt, China, Serbia, Greece & Rome
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➡️ Mercury was used for epidemic diseases since the 1300s & especially syphilis
➡️ However, the treatment could be worse than the disease, with mercury poisoning possible
➡️ Treatment could last years, leading to the saying “A night with Venus, a lifetime with mercury”"
➡️ Throughout history, the most mystical substance of all has been blood
➡️ It has been coveted and desired
➡️ Fought for and defended
➡️ Stolen, yet freely given
A 🧵
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➡️ Blood has always been a symbol of power
➡️ In Greek mythology, ichor, the blood of the Gods, was a golden fluid
➡️ It was immortal, pure, & untainted by human weaknesses
➡️ The Gods derived their divine powers & longevity from it
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➡️ Blood has been revered for its restorative properties
➡️ Elizabeth Báthory, a 16th-century Hungarian noblewoman, allegedly killed hundreds of young girls & women
➡️ She bathed in their blood to maintain her youth & beauty
➡️ There are ~ 5.8 million trauma deaths per year globally
➡️ Trauma is the largest cause of death below the age of 50
➡️ One-third of severely injured trauma patients are coagulopathic at hospital arrival
➡️ Fibrinogen is often used, but is it effective?
a short 🧵
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➡️ Trauma-induced coagulopathy is due to inflammation & shock
➡️ It is worsened by hypothermia, acidosis, and hemodilution
➡️ Coagulopathy due to hemorrhage is strongly associated with mortality
➡️ 1/3 of early trauma deaths are due to uncontrolled haemorrhage
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➡️ Fibrinogen is depleted early during major bleeding
➡️ It can be replaced with fresh frozen plasma, cryoprecipitate or fibrinogen concentrate
➡️ Cryoprecipitate includes fibrinogen, factor VIII coagulant, von Willebrand factor, fibronectin & factor XIII
➡️ Death has always fascinated human civilisations
➡️ Not just the ending of a life, but either preparation for the afterlife or attempts to restore an existing life
A 🧵
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➡️ Ancient Egyptians preserved corpses via mummification for an afterlife
➡️ They removed internal organs, used embalming fluids, linen bandages, & intricate coffins
➡️ The wealthy had pyramids
➡️ Relatives, staff & pets were buried alive for the journey to the afterlife
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➡️ In Greek Mythology, the River Styx separated the worlds of the living & dead
➡️ Charon, the Ferryman, required payment from the deceased for passage
➡️ The dead were buried with a coin
➡️ Those unable to pay were left to wander the river bank for 100 years
➡️It's widely used for treatment & prevention of haemorrhage
➡️It's in the WHO's List of Essential Medicines & recommended in the European Traumatic Haemorrhage guideline (2023)
➡️But is it as efficacious as we think?
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🚩 History
➡️Drs. Utako & Shosuke Okamoto invented TXA in 1962
➡️They identified that the amino acid lysine inhibited the degradation of plasmin, a profibrinolytic enzyme
➡️Lysine was modified to first produce Epsilon- Amino-Caproic Acid and later TXA, x 27 more potent
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🚩 Pharmacology
➡️TXA is a molecular analog of lysine
➡️It inhibits fibrinolysis by preventing the binding of plasminogen to fibrin
➡️This inhibits plasmin formation & displaces plasminogen from the fibrin surface
➡️It also has effects on the immune system & inflammation