Page 72 - JSOM Winter 2018

Feasibility Study Vascular Access and REBOA Placement

From Zero to Hero

B.L.S. Borger van der Burg, MD, FEBVS ; R.C.L.A. Maayen, MD ; Capt T.T.C.F. van Dongen, MD, PhD ;
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CPL Gerben ; CPL-1 Eric ; J.J. DuBose, MD, FACS, USAF MC ; T.M. Hörer, MD, PhD ;
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COL (Ret) M.W. Bowyer, MD, FACS, DMCC ; CDR R. Hoencamp MD, PhD, FEBVS, DMA 1,2,8 *
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ABSTRACT
Background: Vascular access is a necessary prerequisite for the trauma literature as nonsurvivable injuries contributing to-
REBOA placement in patients with severe hemorrhagic shock. ward almost 90% of catastrophic hemorrhage fatalities in the
Methods: During an EVTM workshop, 10 Special Forces prehospital phase, in contrast to a 10% fatality rate in extremity
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(SOF) medics, five combat nurses, four military nonsurgeon injuries (tourniquets). Given a number of recent mass casualty
physicians, and four military surgeons participated in our incidents from shootings and terrorist attacks, new concepts
training program. The military surgeons functioned as the of truncal and junctional bleeding control need to be evalu-
control group. A formalized curriculum was constructed in- ated and possibly implemented. Thabouillot et al. described
cluding basic anatomy and training in access materials for at least a 3% decrease in mortality in a prehospital setting in
resuscitative endovascular balloon occlusion of the aorta Paris when REBOA treatment would have been possible at the
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(REBOA) placement. Key skills were (1) preparation of endo- point of inury. Endovascular balloon occlusion of the aorta is
vascular toolkit, (2) achieving vascular access in the model, a technique in which a compliant balloon is advanced into the
and (3) bleeding control with REBOA. Results: The baseline aorta and then inflated, thereby obstructing flow into the dis-
knowledge of anatomy for SOF medics was significantly less tal circulation of temporary measure. The principles of REBOA
than that for nurses and physicians. Medics had a median time have been used as part of the endovascular and hybrid trauma
of 3:59 minutes to sheath insertion; nurses, 2:47; physicians, and bleeding management or endovascular resuscitation and
2:34; and surgeons, 1:39. Military surgeons were significantly trauma management (EVTM) concept in patients with trun-
faster than medics and military nurses (P = .037 resp. 0.034). cal and junctional injuries involving massive hemorrhage. The
Medics had a median total time from start to REBOA inflation REBOA concept has been used in the hospital setting, combat
of 5:05 minutes; nurses, 4:06; military physicians, 3:36; and environments, and even the earliest phases of prehospital care.
surgeons, 2:36. Conclusion: This study showed that a compre-
hensive theoretical and practical training program using a task An international collaborative workgroup has been developed
training model can be used for percutaneous femoral access to evaluate the safety and efficacy of REBOA and EVTM as
and REBOA placement training of military medical personnel a potential standard for the emergency care of selected pa-
without prior ultrasound or endovascular experience. Higher tients. An important research question is whether it is feasible
levels of training reduce procedure times. to train medical personnel with limited or no prior endovascu-
lar or surgical experience, including prehospital care providers
Keywords: vascular access; training; aortic balloon occlusion; such as nurses and medics, to perform endovascular proce-
military; prehospital dures. There are a few formal training curricula designed for
physicians, to train the skills necessary to perform REBOA.
These include the Basic Endovascular Skills for Trauma ™
(BEST) and the Endovascular Skills for Trauma and Resuscita-
Introduction
™
tion ( ESTARS) and EVTM courses. The EVTM International
Controlling catastrophic bleeding is the major lifesaving skill Collaboration Workgroup has recently reported on a compre-
in trauma and vascular surgery. Recent experiences on the bat- hensive vascular access training program using a live tissue
tlefields of Iraq and Afghanistan have validated the efficacy of simulator hybrid porcine model that can be used for femoral
tourniquets and massive transfusion protocols for managing access and REBOA placement training in medical personnel
extremity hemorrhage. However, areas not amenable to tourni- with different prior training levels. 5
quet application such as the neck, trunk, and junctional regions
continue to represent challenges for prompt bleeding control. The primary aim of this current feasibility study is to determine
Truncal and junctional hemorrhages are often described within whether using a microteaching program on a task training

*Correspondence to CDR R. Hoencamp, MD, PhD, LUMC, Department of Surgery, K6-50, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, the
Netherlands; or r.hoencamp@LUMC or r.hoencamp@mindef.nl
1 Dr Borger van der Burg, Dr Maayen, Capt van Dongen, and CDR dr Hoencamp are affiliated with the Department of Surgery, Alrijne Hospital,
Leiderdorp, the Netherlands. Capt dr van Dongen and CDR dr Hoencamp are affiliated with the Defense Healthcare Organization, Ministry
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of Defense, Utrecht, the Netherlands. CPL Gerben is an SOF medic, Maritime Special Operations Forces. CPL-1 Eric is an SOF medic, Korps
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Commandotroepen. Lt Col prof DuBose is affiliated with the R Adams Cowley Shock Trauma Center, University of Maryland Medical System,
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Baltimore, MD, and the Uniformed Services University of the Health Sciences, Washington, DC. Dr Hörer is affiliated with the Department of
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Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden. COL (ret) dr Bowyer is affiliated with the Department of
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Surgery at Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD. CDR dr
Hoencamp is also affiliated with the Leiden University Medical Centre, Leiden, the Netherlands.
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