The Role of Prehospital REBOA for Hemorrhage Control in Civilian and Military Austere Settings: A Systematic Review
Round 1
Reviewer 1 Report
This systematic review article looks to evaluate the role and effectiveness of prehospital REBOA for hemorrhage control in trauma. The key message can be summarized as; prehospital REBOA is effective for hemorrhage control adjunct in non-compressible torso hemorrhage. The authors also weren’t able to make conclusions on the effects of pre-hospital REBOA use or complications stemming from use. This is not surprising, as these are decades-old questions and controversies surrounding REBOA. This is in part due to the available data. Similarly as the authors mentioned, that there is heterogeneity in the studies, along with the fact that REBOA tends to perform differently between military and civilian settings, likely due to more experience, earlier application, less sick patients, and would need system-wide adoption and standardization rather than just teaching a technique and indications.
Strengths: The authors were able to gather some more data that has become available in the last few years.
Weaknesses: Unable to produce a meta-analysis. Only included 6 articles after paring down the articles from selection. Even with these articles, some were of lower quality such as case reports, and overall data was difficult to compare and integrate. Also with the lack of certain outcome measurements, inferences can only be made of the outcome results. Mixes military trauma setting with civilian trauma, which does not always correlate, especially if they had different zones of deployment.
Overall: It’s an interesting paper that takes the existing data to attempt to clear up the discussion with regards to the effectiveness REBOA use. However, it still encounters the same issues which prolong the nearly 70 year debate. While the intent is commendable and the methods are sound, I’m not sure how much more new information this paper adds to the current knowledge behind REBOA. Similarly, it seems we’re all waiting for the results of the UK-REBOA randomized control trial.
Comments:
- P5L157, 6 studies, but 3 in civilian and 4 in military? Does not match table 3.
- P12L285, assume authors meant window not widow.
- Various places throughout paper, please ensure acronym of non-compressible torso hemorrhage (NCTH) is not written as “NTCH”. There are at least 4 instances.
Author Response
Comment: P5L157, 6 studies, but 3 in civilian and 4 in military? Does not match table 3.
Author response: We are sorry for this confusion. It should be six studies all together. Lines 155-159 have been amended to reflect this.
Comment: P12L285, assume authors meant window not widow.
Author response: Corrected to ‘window’ (now Line 278).
Comment: Various places throughout paper, please ensure acronym of non-compressible torso haemorrhage (NCTH) is not written as “NTCH”. There are at least 4 instances.
Author response: 3 occurrences of NTCH were amended to NCTH. Thank you.
Reviewer 2 Report
I would like to thank the authors for allowing me to review their paper looking at pre-hospital REBOA. Besides military settings, or Western high-density urban settings with large amounts of penetrating trauma (criminal activity), it is unlikely that pre-hospital REBOA will ever find a role. Irregardless, this review does a good job summarising the, or alternatively highlighting the paucity of, evidence surrounding the patient population, setting and heterogenous outcomes.
There is no mention of registration with PROSPERO, however I do see there is a Colombian group planning to interrogate the same question. There have obviously been multiple SRMAs looking at hospital level REBOA use, with the data quality allowing a MA synthesis, but the authors demonstrate that variables and outcomes are so heterogenous that this is impossible.
Thus as review, it is essentially narrative. I have no direct issues with the content, as it illuminates the problems with the existing literature and cautions drawing strong conclusions. The limitations are well explored, and I would add there may be a publication bias not only for the English language, but also for patient survival. A case study of n=1 is unlikely to be published if the patient arrested in the back of a humvee.
In regards to the conclusion itself, I would truncate it. Keep it simple to 3-4 lines. Acknowledge that there appears to be benefit in select cases that were published, but with the poor evidence quality, conclusions need to be cautiously interpreted. You have made most of your points in the conclusion already in the text.
Author Response
Comment: I would like to thank the authors for allowing me to review their paper looking at pre-hospital REBOA. Besides military settings, or Western high-density urban settings with large amounts of penetrating trauma (criminal activity), it is unlikely that pre-hospital REBOA will ever find a role. Irregardless, this review does a good job summarising the, or alternatively highlighting the paucity of, evidence surrounding the patient population, setting and heterogenous outcomes.
Author response: Thank you for your kind words.
Comment: There is no mention of registration with PROSPERO, however I do see there is a Colombian group planning to interrogate the same question. There have obviously been multiple SRMAs looking at hospital level REBOA use, with the data quality allowing a MA synthesis, but the authors demonstrate that variables and outcomes are so heterogenous that this is impossible.
Author response: We have not registered this PROSPERO.
Comment: Thus, as review, it is essentially narrative. I have no direct issues with the content, as it illuminates the problems with the existing literature and cautions drawing strong conclusions. The limitations are well explored, and I would add there may be a publication bias not only for the English language, but also for patient survival. A case study of n=1 is unlikely to be published if the patient arrested in the back of a humvee.
Author response: Thank you and we agree with the limitations of publication bias which was already mentioned. We have added patient survival also as a potential bias limiting our study.
Comment: In regards to the conclusion itself, I would truncate it. Keep it simple to 3-4 lines. Acknowledge that there appears to be benefit in select cases that were published, but with the poor evidence quality, conclusions need to be cautiously interpreted. You have made most of your points in the conclusion already in the text.
Author response: Conclusions have been shortened to 4 lines containing the recommended information suggested by this reviewer.
Round 2
Reviewer 1 Report
All my comments were addressed, no further issues.
Reviewer 2 Report
I would like to thank the authors for their modifications. The manuscript is currently acceptable in it's current format.
