Can Artificial Intelligence Improve the Appropriate Use and Decrease the Misuse of REBOA?

The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for control of noncompressible torso hemorrhage remains controversial. We aimed to utilize a novel and transparent/interpretable artificial intelligence (AI) method called Optimal Policy Trees (OPTs) to improve the appropriate use and decrease the misuse of REBOA in hemodynamically unstable blunt trauma patients.

We trained and then validated OPTs that "prescribe" REBOA in a 50:50 split on all hemorrhagic shock blunt trauma patients in the 2010-2019 ACS-TQIP database based on rates of survival. Hemorrhagic shock was defined as a systolic blood pressure ≤90 on arrival or a transfusion requirement of ≥4 units of blood in the first 4 h of presentation. The expected 24 h mortality rate following OPT prescription was compared to the observed 24 h mortality rate in patients who were or were not treated with REBOA.

Out of 4.5 million patients, 100,615 were included, and 803 underwent REBOA. REBOA patients had a higher rate of pelvic fracture, femur fracture, hemothorax, pneumothorax, and thoracic aorta injury (p < 0.001). The 24 h mortality rate for the REBOA vs. non-REBOA group was 47% vs. 21%, respectively (p < 0.001). OPTs resulted in an 18% reduction in 24 h mortality for REBOA and a 0.8% reduction in non-REBOA patients. We specifically divert the misuse of REBOA by recommending against REBOA in cases where it leads to worse outcomes.

This proof-of-concept study shows that interpretable AI models can improve mortality in unstable blunt trauma patients by optimizing the use and decreasing the misuse of REBOA. To date, these models have been used to predict outcomes, but their groundbreaking use will be in prescribing interventions and changing outcomes.