Pump Up that Balloon Before Your Patient is Doomed: REBOA in Trauma

Hemorrhage is the leading cause of death in trauma. Patients with intra abdominal, pelvic, or intrathoracic hemorrhages have an extremely high mortality rate. Prehospital providers can only fix one of the two types of hemorrhages. The categories of hemorrhages include:

  1. Compressible- Can be stopped with direct pressure/tourniquet (usually on the extremities).
  2. Non-compressible- Usually happens in the thoracic or abdominal cavity.

We should know how to deal with compressible hemorrhages. Direct pressure, tourniquet application (high and tight due to the artery constricting and moving away from the injury sight), and wound packing with hemostatic gauze.

The Silver Bullet Blog | Ready Warrior LLC
https://readywarriorllc.com/blogs/battlefield-medicine/tagged/care-under-fire

But what about our non-compressible hemorrhages? Well that is where REBOA comes in.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is commonly used in trauma surgeries to prevent extreme blood loss which can lead to hemorrhagic shock. This is an answer (notice how I didn’t say THE answer) for our hemodynamically unstable trauma patients who are bleeding into the abdominal cavity, thoracic cavity, or even the pelvis. So what is REBOA?

REBOA is when a clinician introduces a catheter into the common femoral artery. From there, the device is advanced into one of two zones of the aorta where the balloon is inflated. There are three zones of the aorta but only two are utilized because in Zone 2 it is very difficult to occlude the artery.

Podcast Episode 30: REBOA?! with Joe DuBose – ProlongedFieldCare.org
https://prolongedfieldcare.org/2017/11/01/podcast-episode-30-reboa-use-for-pfc-with-joe-dubose-2/

Here is the procedure video if you wish to watch it:

https://www.youtube.com/watch?v=WYg7xjhq6UE

The three zones of the aorta I mentioned are:

Zone 1: origin of the subclavian artery to the celiac artery

Zone 2: Celiac artery to the lowest renal artery (this is an unused site for placement of REBOA)

Zone 3: The lowest renal artery to the aortic bifurcation

You can confirm the zone using X-ray or fluoroscopy (similar to an X ray but isn’t a snapshot like an X-ray, it is similar to a movie). So which patients need REBOA?

Indications

If you notice their Systolic BP is less that 90 mmHg, try resuscitating them with some blood. If they don’t respond to treatment, they are a “non responder”; if they do respond to treatment, they are a “responder”. Patient’s that are considered a “responder” are not a candidate for this procedure.

http://prytimemedical.com/wp-content/uploads/2017/05/reboa-algorithm-maryland-shock-trauma.pdf

Here is a more in-depth algorithm

https://mtqip.org/sites/default/files/downloads/180213%20REBOA%20Napolitano.pdf
https://mtqip.org/sites/default/files/downloads/180213%20REBOA%20Napolitano.pdf

Other indications:

  1. Severe abdominal/pelvic/junctional or proximal lower extremity hemorrhage that can’t be controlled.
  2. Cardiac arrest patients with blunt or penetrating trauma inferior to the diaphragm with suspected non-compressible hemorrhage (this should probably be done along with a resuscitative thoracotomy).
  3. Trauma inferior to the diaphragm and to the femoral arteries.
  4. Patients 18-69 years old

After extensive research, many sites can’t agree on all of the information. So We tried to pull the results that most sites agree on. Use in patients in traumatic arrest vary. Just make sure you follow your clinical guidelines.

Contraindications

  1. Aorta injury
  2. Penetrating trauma to the head or neck
  3. Major chest injury
  4. Pediatrics
  5. Patients over 70 years old

Complications of REBOA

  1. Aortic dissection/aneurysm
  2. Extremity ischemia
  3. Prolonged occlusion can cause organ or spinal cord ischemia/injury
  4. Inflation in the iliac arteries can cause rupture or thrombus

So obviously when you block blood flow to anything, you are going to have some complications right?

Final Thoughts

The use of REBOA is obviously very important in our non-compressible critically ill trauma patients. But it is not without its complications. This should be done by a REBOA certified physician. While REBOA can be a life-saving procedure, it’s important to not forget about things such as securing the pelvis, obtaining IV access, performing x-rays, obtaining a definitive airway, and controlling compressible hemorrhage. ABCs are always #1 in patient care. The Jackson 5 song should constantly be playing in your head.

With that being said, there’s been some studies showing promise of it being used in the critical care prehospital setting. Currently there’s not enough strong evidence to support it’s use in the prehospital setting. Could this be implemented successfully in the prehospital setting on a more consistent basis? I guess only time and research can decide that.

This site is meant to be used for educational use only. We strive to push evidence based medicine with no bias to help you obtain all the important information. You should always follow your protocols that have been set in place

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References

https://www.youtube.com/watch?v=E6MlDWi9Oek

Astin, M. (2020, January 30). REBOA Time. Retrieved September 27, 2020, from https://rebelem.com/reboa-time/

Brenner, M., Bulger, E., Perina, D., Henry, S., Kang, C., Rotondo, M., . . . Stewart, R. (2018, January 01). Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Retrieved September 27, 2020, from https://tsaco.bmj.com/content/3/1/e000154

Bulger, E., Perina, D., Qasim, Z., Beldowicz, B., Brenner, M., Guyette, F., . . . Stewart, R. (2019, September 20). Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: A joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians. Retrieved September 27, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802990/

L;, D. (2017, January 12). The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to ACLS in non-traumatic cardiac arrest. Retrieved September 27, 2020, from https://pubmed.ncbi.nlm.nih.gov/28117180/

Nickson, C. (2019, March 30). REBOA in resuscitation • LITFL • CCC resuscitation. Retrieved September 27, 2020, from https://litfl.com/reboa-in-resuscitation/

Pasley, J., Cannon, J., Glaser, J., Polk, T., Morrison, J., Brocker, J., . . . Stockinger, Z. (n.d.). Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Hemorrhagic Shock. Retrieved September 26, 2020, from https://jts.amedd.army.mil/assets/docs/presentations/REBOA_CPG_Training_ID38.pdf

Thomas, M., & Malik, D. (2016, September 27). REBOA: A Precious (Life)line. Retrieved September 27, 2020, from https://www.emra.org/emresident/article/reboa-a-precious-lifeline/

Zenoni, S., MD, & Ibrahim, J., MD. (2018, July 24). RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA (REBOA) (948538860 740004147 M. Cheatham MD & 948538861 740004147 C. Smith MD, Eds.). Retrieved September 26, 2020, from http://www.surgicalcriticalcare.net/Guidelines/REBOA%202018.pdf

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