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01.12.2017 | Case report | Ausgabe 1/2017 Open Access

Journal of Medical Case Reports 1/2017

Resuscitative endovascular balloon occlusion of the aorta may increase the bleeding of minor thoracic injury in severe multiple trauma patients: a case report

Zeitschrift:
Journal of Medical Case Reports > Ausgabe 1/2017
Autoren:
Takaaki Maruhashi, Hiroaki Minehara, Ichiro Takeuchi, Yuichi Kataoka, Yasushi Asari
Abbreviations
Bpm
Beats per minute
CT
Computed tomography
REBOA
Resuscitative endovascular balloon occlusion of the aorta

Background

Temporary aortic occlusion may be performed prior to definitive hemostasis for trunk injury accompanied by hemorrhagic shock in which bleeding control is difficult. Aortic occlusion was conventionally performed by cross-clamping the aorta after resuscitative thoracotomy. In recent years, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been widely used to treat patients with severe torso trauma. It has been reported that invasion by REBOA is much lower than that in the case of cross-clamping, and although there are no significant differences in the time required for occlusion, the use of REBOA correlates with higher survival rates [1]. Therefore, cross-clamping after thoracotomy has been replaced with the aortic occlusion technique because of the latter’s greater efficacy and feasibility.
Although great benefits are expected as described above, complications related to catheter insertion are known as common complications accompanying REBOA: vascular injury, aorta dissection, aberration of the catheter, and organ ischemia of the site distal to the occlusion accompanied by prolonged occlusion. However, complications developing around the site proximal to the occlusion, such as the possibility of increase in bleeding in the site proximal to the occlusion and the side effects of hyperperfusion, have hardly been studied to date. A systematic review [2] of REBOA, which included 61 articles and 1355 patients, showed that complications of the site proximal to the occlusion occurred only in one patient (0.07%) [3].
We experienced a case of severe multiple trauma with impending cardiac arrest, in which REBOA was used to avoid cardiac arrest, where REBOA possibly caused major bleeding from a thoracic injury that had been diagnosed as mild at initial arrival.
Here we report this case to raise a concern that the use of REBOA may cause unclarified bleeding complications at sites proximal to an occlusion.

Case presentation

A 50-year-old Japanese woman fell from a height of approximately 10 m and was brought to our hospital by an ambulance. She had no remarkable medical and family history, was a social drinker, and a non-smoker of tobacco. Her marital status was stable with her husband. Her consciousness levels were 14 points (E4, V4, M6) according to the Glasgow Coma Scale at initial arrival. She complained of respiratory discomfort and low back pain, and was in an unrestful state. Her respiratory rate was 24 breaths/minute, blood oxygen saturation (SpO2) was 95% under 10 L/minute oxygenation, subcutaneous emphysema was recognized in the left side of her chest, and her breathing sounded weak. A hemoperitoneum was not detected on focused assessment with ultrasonography for trauma. Her pulse rate was 90 beats per minute (bpm) and her blood pressure was 180/120 mmHg as measured by an automatic blood pressure monitor. However, her capillary refill time was 3 seconds and radial artery pulsation was feeble with cold sweat in her extremities; hence, she was recognized as being in a state of shock. Her face swelled, and bleeding from her nasal and the oral cavities continued. A subcutaneous hematoma was found in her lumbar and her left femoral region. Her left elbow was deformed and swollen. Because she was in a restless state, accurate neurological assessments were difficult, but coarse paralysis of limbs was not observed.
First, a 28-French chest drain was inserted in her left thoracic cavity for the diagnosis of tension pneumothorax. Hemothorax was not recognized. A pelvis X-ray showed unstable pelvic fracture and a contrast-enhanced computed tomography (CT) pan scan was additionally performed. In the contrast CT, retroperitoneal bleeding with the extravasation of contrast media was recognized (Fig. 1). Other injuries and laboratory data on initial arrival are shown in Tables 1 and 2 respectively.
Table 1
Injury site and diagnosis of this case along with Abbreviated Injury Scale coding
Body region
Diagnosis
Head and neck
Brain contusion (brain stem, cerebrum)
Face
Mandible fracture
Zygoma fracture
Nose fracture
Chest
Multiple rib fractures
Hemopneumothorax
Thoracic spine fracture
Abdominal
Liver laceration
Lumbar spine fracture
Extremities and pelvis
Femoral neck fracture
Pelvic fracture
External
None
Injury severity score: 66
Probability of survival: 59.3%
Table 2
Laboratory data on initial arrival
Complete blood count
 WBC
4500
/μl
 Neu
71.8
%
 Lym
24.9
%
 RBC
378
× 104/μl
 Hb
11.6
g/dl
 Ht
34.4
%
 Plt
22.5
× 104/μl
Arterial blood gas (10 L/minute oxygenation)
 pH
7.451
 
 PO2
41.7
mmHg
 PCO2
251.3
mmHg
 HCO3 -
28.4
mmol/l
 BE
4.1
mmol/l
 Lac
43.4
mg/dl
Chemistry
 TP
6.0
g/dl
 Alb
3.8
g/dl
 BUN
12.6
mg/dl
 Cre
0.84
mg/dl
 Na
135
mEq/l
 K
3.3
mEq/l
 Cl
97
mEq/l
 Ca
9.1
mg/dl
 AST
321
U/l
 ALT
217
U/l
 LDH
902
U/l
 ALP
170
U/l
 T-Bil
1.3
mg/dl
 CPK
450
U/l
 CRP
0.03
mg/dl
Coagulation
 APTT
30.3
seconds
 PT
65
%
 PT-INR
1.23
 
 Fib
171
mg/dl
 FDP
80.5
μg/ml
 D-dimer
40.16
μg/ml
Alb albumin, ALP alkaline phosphatase, ALT alanine aminotransferase, APTT activated partial thromboplastin time, AST aspartate aminotransferase, BE base excess, BUN blood urea nitrogen, Ca calcium, Cl chlorine, CPK creatine phosphokinase, Cre creatinine, CRP C-reactive protein, FDP fibrin degradation product, Fib fibrinogen, Hb hemoglobin, HCO 3 - bicarbonate, Ht hematocrit, K potassium, Lac lactate, LDH lactate dehydrogenase, Lym lymphocyte, Na sodium, Neu neutrophil, PCO 2 partial pressure of carbon dioxide, Plt platelets, PO 2 partial pressure of oxygen, PT prothrombin time, PT-INR prothrombin time-international normalized ratio, RBC red blood cells, T-Bil total bilirubin, TP total protein, WBC white blood cells
The injury severity score in this case was 66 and the probability of survival was calculated as 59.3%. Multiple rib fractures were seen, even though active bleeding from intercostal artery injury and pulmonary laceration were not noted at the initial visit. She had deteriorated during CT (blood pressure 67/42 mmHg, pulse rate 75 bpm), and blood transfusion was therefore started and intubation was performed. Transcatheter arterial embolization was performed for hemorrhagic shock with the pelvic fracture as the main bleeding source. While starting angiography, she did not respond to the massive blood transfusion and her systolic blood pressure was maintained at around 60 mmHg. Therefore, first, a 7-French aortic occlusion catheter (RESCUE BALLOON®, Tokai Medical Products, Aichi, Japan) was inserted from her left femoral artery. Her hemodynamics had improved and her systolic blood pressure was 90 mmHg due to REBOA (30 mL saline inflation into the balloon) at the first lumbar vertebra level. Next, transcatheter arterial embolization was started using the sheath inserted in her right femoral artery. Her bilateral internal iliac arteries were embolized from the origin portion with a gelatin sponge. Furthermore, we embolized the extravasation of contrast media of her middle sacral artery and lumbar artery with n-butyl-2-cyanoacrylate. Her blood pressure had been monitored by continuous invasive arterial measurement from her upper right brachial artery during interventional radiology. The systolic blood pressure under REBOA was intended to be controlled under 100 mmHg (so called permissive hypotension); however, it was actually in the range of 90 to 160 mmHg. After 18 minutes of occlusion, the balloon was deflated and the aortic occlusion catheter was removed. However, she was still hemodynamically unstable. The internal iliac artery angiography was performed again, and the site that had just been embolized, as described above, presented recanalization. Since coagulopathy was recognized as a complication, we interpreted that it would be difficult to restrain the hemorrhage with the gelatin sponge. Therefore, it was re-embolized from the origin portion of her bilateral internal iliac arteries by n-butyl-2-cyanoacrylate (Fig. 2). After embolization, retroperitoneal gauze packing and pelvic external skeletal fixation were additionally performed. Further, a repeat CT pan scan was performed, and a massive hemothorax had appeared in her left pleural cavity, which had not been captured at the first arrival (Fig. 3). As the inserted chest drain at the first arrival was detained between lobes, the amount of bleeding in the pleural cavity had not been reflected precisely. Thoracotomy hemostasis was performed and a hemothorax of approximately 2500 ml was aspirated to search for the source of the bleeding. However, clear active bleeding was not captured and only extremely minute bleeding from the rib fracture site, chest wall, and pulmonary contusion area was detected. Therefore, special hemostasis treatment was not needed. After a massive hematoma was removed, a chest drain was placed again and her chest was closed. Continuous blood transfusion was not needed before or after the operation and her postoperative hemodynamics became stable. The timeline of the initial treatment in our emergency department is shown in Table 3.
Table 3
The timeline of initial treatment in our emergency department
Time course after arrival at the hospital
Survey and treatment
0 min
Hospital arrival
5 min
Fluid resuscitation start
10 min
Left chest drain insertion
12 min
Focused assessment with ultrasonography for trauma
19 min
Chest and pelvis X-ray
44 min
Whole body CT scan
57 min
Transfusion start
72 min
Intubation
83 min
Endovascular treatments start
Resuscitative endovascular balloon occlusion of the aorta
100 min
The bilateral internal iliac arteries were embolized
101 min
The balloon of the aortic occlusion catheter was deflated
Retroperitoneal gauze packing
Pelvic external skeletal fixation
600 min
Repeat CT scan
631 min
Thoracotomy hemostasis for left massive hemothorax
CT computed tomography, min minutes
The retroperitoneal packing gauze was removed on day 3. On day 24, the chest drain was removed without increasing the hemothorax. Complications accompanied by internal iliac artery occlusion, such as gluteal muscle necrosis, did not appear. She regained the ability to walk, and was moved to another hospital on day 154 for rehabilitation. She was discharged from the rehabilitation hospital 6 months after the injury, and her activities of daily living were almost independent.

Discussion

This case was in a state of threatened cardiac arrest from hemorrhagic shock due to pelvic fracture, but cardiac arrest was avoided by REBOA. However, bleeding of the thoracic injury proximal to the occlusion increased over time, and additional thoracotomy hemostasis was required. The CT at the initial arrival had presented only mild lung contusion. Arterial hemorrhage that resulted in massive hemothorax in a short time was not shown. It is known that delayed massive hemothorax develops in 7.4% of blunt thoracic injuries with rib fracture, even if it is a minor injury in the initial diagnosis [4]. It usually develops from 18 hours to 6 days (3 days on an average) after injury [5]. Moreover, its cause is bleeding from the intercostal artery in most cases, but diaphragm injuries can also be the cause in some cases. In this study, the findings obtained by CT and open thoracotomy after the removal of the aortic occlusion did not show active bleeding, and intercostal aneurysms and diaphragm injuries were not confirmed. In a head and pelvic injury case treated by REBOA, Uchino et al. reported that a complication developed in the site proximal to the occlusion by REBOA in which minor intracranial bleeding was seen in the head CT at the initial diagnosis, wherein the bleeding suddenly increased and a cerebral hernia developed and the patient died [3]. In this case, REBOA excessively raised the perfusion pressure in the chest area proximal to the occlusion, and coagulopathy occurred, induced by trauma shock and trauma itself. Therefore, we considered that bleeding accompanied by extremely minor thoracic injury had increased unexpectedly.
Several methods to avoid complications while performing insertions have been reported, such as the insertion method with ultrasonography [6, 7], insertion training with a cadaver [8], and the use of smaller introducer sheaths for REBOA [9]. In fact, it has also been reported that a good outcome was obtained by REBOA in the course of prehospital care for severe pelvic fracture as it can be inserted safely without fluoroscopy [10].
However, only a few studies have focused on blood flow evaluation at the site proximal to the occlusion in an aortic occlusion, or discussed perfusion pressure in detail. Therefore, a clear standard does not exist for the best occlusion rate, or for bleeding control at a site distal from the occlusion without increasing bleeding at a site proximal to the occlusion. Furthermore, it has been reported that in an analysis of data from the Japan Trauma Data Bank, the use of REBOA increased mortality compared with that of cases without REBOA [11]. REBOA is a revival treatment required in an emergency situation, where there is no other way but to employ REBOA, and it is used at a stage when, it is assumed, detailed information about the lesion and the severity has not yet been grasped. Furthermore, since the frequency of its use is expected to rise in various situations both in and out of hospital for trauma and endogenous diseases in the future, it is necessary to study the evaluation of blood flow at the site proximal to occlusions, the optimal methods of monitoring such blood flow, and the optimal occlusion rates.

Conclusions

A method for the evaluation of blood flow has not been established for sites proximal to occlusions by REBOA. We report this case to call attention to the use of REBOA which may increase bleeding in sites proximal to occlusions unexpectedly in multiple trauma with head or thoracic injuries, even in the case of minor injuries without active bleeding at the initial diagnosis.

Acknowledgements

The authors would like to thank Enago (www.​enago.​jp) for the English language review.

Funding

This report did not receive any funding.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Ethics approval and consent to participate

This case report was approved by the Kitasato University Ethics Committee (approval number B16-120).

Consent for publication

Written informed consent was obtained from the patient for publication of this case report, the accompanying images, and the laboratory data. A copy of this report is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

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