Page 27 - Journal of Special Operations Medicine - Spring 2017

Discussion thoracotomy but with significantly lower pulmonary
complication rates. This active registry promises to
To our knowledge, this case series is the first to describe provide additional information on the use of REBOA,
REBOA in the management of wartime injury and the including a better understanding of the optimal applica-
only description demonstrating the effectiveness of the tion of this resuscitative adjunct.
new ER-REBOA catheter in this setting. In the series,
REBOA was performed in the out-of-hospital setting by Technical Considerations
a multidisciplinary team, none of whom had received REBOA has been shown to be successful for the resus-
formal vascular, endovascular, or trauma surgery train- citation of patients with noncompressible torso injuries
ing. This experience demonstrates the feasibility of posi- in the civilian setting, and this report demonstrates that
tioning and inflation of the ER-REBOA catheter without effectiveness can be achieved in austere military environ-
the use of radiography. It also underscores the value of ments. There are, however, several clinical and technical
a handheld ultrasound device as a multifaceted tool in considerations that must be emphasized when REBOA
this setting that can aid diagnosis of hemoperitoneum, is to be undertaken in either setting.
guide arterial access, and examine extremity perfusion
after removal of the REBOA sheath. Findings from this Training
report confirm that REBOA can be safely and effectively Experience has demonstrated that providers who do not
incorporated into a lifesaving resuscitative capability routinely use advanced endovascular techniques can ob-
delivered closer to the point of injury during the most tain the skillset for safe and effective REBOA. Modern
4
critical phases of casualty management.
surgeons and emergency physicians are commonly well
versed in techniques of arterial access, with ultrasound-
Context of Existing Reports guided access emerging as a standard of care. Neverthe-
The current case series extends a growing list of clini- less, standardized training incorporating these elements
cal reports describing the use of REBOA since its recent with the additional steps of REBOA, including the po-
reappraisal as a management approach for trauma and tential need for femoral cut-down to access vessels in
hemorrhagic shock. 1–5,19 Brenner and colleagues were patients in extremis, is recommended.
2
among the first to document a modern clinical experi-
ence with this adjunct, reporting on the use of REBOA Several training courses have been developed to provide
in six severely injured and bleeding civilian patients, training in REBOA. The Endovascular Skills for Trauma
none of whom died of hemorrhage. In a subsequent and Resuscitative Surgery (ESTARS) course collabora-
study by Moore and colleagues, investigators reported tively offered by the University of Michigan and the
1
the results of a cohort study of civilian trauma patients DoD Combat Casualty Care Research Program is de-
21
with infradiaphragmatic bleeding who underwent either signed to provide training in vascular trauma procedures
REBOA (n = 24) or resuscitative thoracotomy with aor- to general and acute care surgeons. Another alternative,
tic clamping (n = 72). Patients who underwent REBOA developed at the R. Adams Cowley Shock Trauma Cen-
had fewer early deaths and had improved overall sur- ter in Baltimore, Maryland, is the BEST course. 22,23 This
vival compared with patients who had undergone tho- course is dedicated expressly to the techniques required
racotomy. A recent systematic review of the literature for REBOA following trauma. Initial results of the BEST
conducted by Morrison et al. carefully examined the course have demonstrated it can help improve the skills
6
modern experience with REBOA. Among 83 studies and understanding of REBOA among surgeons and
22
available for review, the investigators noted a mean emergency physicians. These courses have now trained
SBP increase of greater than 50mmHg achieved with hundreds of surgical and emergency medicine provid-
REBOA after significant traumatic injury with bleed- ers in the principles of REBOA, including the surgeons
ing. These authors also noted that, despite the presence and emergency medicine providers of the medical unit
of severe shock in 75% of patients, survival after using described in this report.
REBOA as a resuscitative adjunct was 49%.
Patient Selection
The American Association for the Surgery of Trauma Although most reported cases of REBOA performed in
Aortic Occlusion for Resuscitation in Trauma and the civilian setting have occurred after blunt mechanisms
Acute Care Surgery prospective registry was initiated in of injury, the data suggest that REBOA can also be effec-
2013 to document and examine the growing experience tively used after penetrating mechanisms. 1,2,4 Our present
with REBOA in modern trauma care. In the initial re- report illustrates successful REBOA after high-velocity
port from this registry, the investigators presented the gunshot wounds and fragmentation injuries. It is impor-
findings from 46 civilian trauma victims managed with tant to recognize that concerns remain about the place-
REBOA. These authors found that REBOA resulted in ment of a REBOA catheter without full certainty that
4
overall survival rates similar to those of resuscitative there are no major arterial sources of hemorrhage above

REBOA in CCC Setting 5