From the Department of Surgery, San Antonio Military Medical Center (K.S.S., E.N.H., M.M.T., J.J.G.); Department of Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio (L.E.N., C.G.M., P.J.H., D.R.B., M.S., M.M.T., S.C., J.J.G.), JBSA-Fort Sam Houston; and Austin Shock Trauma (J.J.G.), St David's South Austin Medical Center, Austin, Texas.
J Trauma Acute Care Surg. 2021 Feb 1;90(2):369-375. doi: 10.1097/TA.0000000000003024.
Uncontrolled hemorrhage is the leading cause of potentially survivable combat casualty mortality, with 86.5% of cases resulting from noncompressible torso hemorrhage. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive technique used to stabilize patients with noncompressible torso hemorrhage; however, its application can take an average of 8 minutes to place. One therapeutic capable of bridging this gap is adenosine-lidocaine-magnesium (ALM), which at high doses induces a reversible cardioplegia. We hypothesize by using ALM as an adjunct to REBOA, the ALM-induced cardiac arrest will temporarily halt exsanguination and reduce blood loss, allowing for REBOA placement and control of bleeding.
Male Yorkshire swine (60-80 kg) were randomly assigned to REBOA only or ALM-REBOA (n = 8/group). At baseline, uncontrolled hemorrhage was induced via a 1.5-cm right femoral arteriotomy, and hemorrhaged blood was quantified. One minute after injury (S1), ALM was administered, and 7 minutes later (T0), zone 1 REBOA inflation occurred. If cardiac arrest ensued, cardiac function either recovered spontaneously or advanced life support was initiated. At T30, surgical hemostasis was obtained, and REBOA was deflated. Animals were resuscitated until they were humanely euthanized at T90.
During field care phase, heart rate and end-tidal CO2 of the ALM-REBOA group were significantly lower than the REBOA only group. While mean arterial pressure significantly decreased from baseline, no significant differences between groups were observed throughout the field care phase. There was no significant difference in survival between the two groups (ALM-REBOA = 89% vs. REBOA only = 100%). Total blood loss was significantly decreased in the ALM-REBOA group (REBOA only = 24.32 ± 1.89 mL/kg vs. ALM-REBOA = 17.75 ± 2.04 mL/kg, p = 0.0499).
Adenosine-lidocaine-magnesium is a novel therapeutic, which, when used with REBOA, can significantly decrease the amount of blood loss at initial presentation, without compromising survival. This study provides proof of concept for ALM and its ability to bridge the gap between patient presentation and REBOA placement.
失血性休克是导致有抢救希望的战斗伤员死亡的主要原因，其中 86.5%的病例源于无法进行压迫止血的躯干出血。主动脉球囊阻断复苏术（REBOA）是一种用于稳定无法进行压迫止血的躯干出血患者的微创技术；然而，其应用平均需要 8 分钟才能完成。一种有能力填补这一空白的治疗方法是腺苷-利多卡因-镁（ALM），它在高剂量下可诱导出一种可逆的心脏停搏。我们假设，通过将 ALM 作为 REBOA 的辅助手段，ALM 诱导的心脏停搏将暂时停止出血，减少失血，从而使 REBOA 得以放置并控制出血。
雄性约克夏猪（60-80 千克）被随机分为仅接受 REBOA 治疗或 ALM-REBOA 治疗（每组 8 只）。在基线时，通过 1.5 厘米右侧股动脉切开术诱导非控制性出血，并对出血血液进行量化。在损伤后 1 分钟（S1）时给予 ALM，7 分钟后（T0）进行区域 1 REBOA 充气。如果发生心脏骤停，心脏功能要么自行恢复，要么启动高级生命支持。在 T30 时，进行手术止血，并放气 REBOA。动物复苏至 T90 时实施安乐死。
在现场护理阶段，ALM-REBOA 组的心率和呼气末 CO2 明显低于仅接受 REBOA 治疗组。虽然平均动脉压从基线显著下降，但在整个现场护理阶段，两组之间没有观察到显著差异。两组的存活率没有显著差异（ALM-REBOA=89%，仅接受 REBOA 治疗=100%）。ALM-REBOA 组的总失血量明显减少（仅接受 REBOA 治疗=24.32±1.89 毫升/千克，ALM-REBOA=17.75±2.04 毫升/千克，p=0.0499）。
腺苷-利多卡因-镁是一种新型治疗方法，当与 REBOA 联合使用时，可在初始表现时显著减少失血量，而不影响存活率。本研究为 ALM 及其在患者表现与 REBOA 放置之间架起桥梁的能力提供了概念验证。
