Page 24 - Journal of Special Operations Medicine - Spring 2017

civilian trauma setting where older technologies such as Figure 1 Field expedient, portable resuscitation and operative
the Cook Coda (Cook Medical Devices, https://www area deployed in an austere environment area of opportunity.
®
.cookmedical.com/) balloon were used. 1,2,4,18,19 Although
effective, the larger size of many existing occlusion bal-
loon catheters and their need to be placed over a long
stiff wire with radiographic or fluoroscopic guidance
have limited their use in emergent settings.

In 2015, the Food and Drug Administration approved
a new endovascular occlusion balloon for trauma—the
ER-REBOA catheter (Prytime Medical, http://prytime
™
medical.com/). This device was the result of a DoD–
18
civilian research, development, and commercializa-
tion effort and was designed specifically for emergency
trauma use. The ER-REBOA is low profile (7F catheter),
has catheter shaft markers to guide depth of insertion,
and is designed for “single-pass” use, obviating the need
for a traditional “over-the-wire” insertion maneuver.
These features were designed to minimize risk, facilitate
percutaneous placement, and enable its use in scenarios
where radiography is not feasible. The ER-REBOA also
possesses a central lumen for monitoring central arterial
pressure, should this be necessary for scenarios in which
proactive monitoring in patients prone to cardiovascu- Provider Background and Medical Capabilities
lar collapse is desired. The SOST is a multidisciplinary treatment team com-
prising a general surgeon, emergency medicine physi-
To date, published reports of REBOA include only civil- cian, certified registered nurse anesthetist, critical care
ian trauma care scenarios. To our knowledge, no series registered nurse, surgical technician, and respiratory
has described use of the new ER-REBOA catheter. The therapist. Members of the team undergo specialized re-
objective of this paper is to report the first series of ca- cruitment, assessment, and selection, with new members
sualty care scenarios in which REBOA was used as a participating in team-centric, advanced austere, and far-
hemorrhage control and resuscitation adjunct by a mod- forward medical/surgical training. The team continu-
ern military surgical team in a forward (out-of-hospital) ally performs advanced medical and tactical training to
environment, and provide the first series documenting maintain readiness and proficiency.
the use of the new ER-REBOA catheter in the manage-
ment of hemorrhagic shock. Surgical and emergency medicine team members in-
volved in this case series had undergone previous train-
ing in use of REBOA during their attendance at the Basic
Patients and Methods Endovascular Skills for Trauma (BEST ) course. The
™
providers are active-duty Servicemembers assigned to in-
Casualty Care Environment tegrated faculty positions at an American College of Sur-
The four casualties described were evaluated and treated geons Level I Trauma Center, where currency in trauma
by a US Air Force Special Operations Surgical Team capabilities is a routine part of their daily practice.
(SOST). SOST is a highly specialized unit providing sur-
gery and resuscitation in austere environments (Figure
1). These patients were treated in a far-forward casu- Results
alty collection point in an antiaccess and aerial-denial Over 2 months, four patients with combat-related
environment with only damage control or abbreviated trauma and significant NCTH sources were treated us-
surgical capability and limited blood supply augmented ing REBOA. All patients were men who sustained pene-
by locally procured, type-specific whole blood. On aver- trating injuries. Three of the patients sustained multiple
age, between 10 and 15 casualties per day were man- gunshot wounds to the lower chest or lower abdomen.
aged at this location, which was approximately 3 km The fourth victim had diffuse fragmentation injuries
(10–15 minutes) from the point of injury and 2 hours by due to explosive ordinance, with the preponderance of
ground transport from the next highest environment of significant injury burden to the lower abdomen and in-
care, a Role 2 equivalent. guinal region. All casualties were delivered directly to

2 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017