Page 39 - Journal of Special Operations Medicine - Spring 2017

Resuscitative Endovascular Balloon Occlusion of the Aorta
Pushing Care Forward

William Teeter, MD, MS; Anna Romagnoli, MD; Jacob Glaser, MD;
Andrew Fisher, MPAS, PA-C; Jason Pasley, DO; Brian Scheele, DO;
Melanie Hoehn, MD; Megan Brenner, MD, MS

ABSTRACT

Background: Resuscitative endovascular balloon occlu- and coalition forces. Survival to a Role 3 medical treat-
sion of the aorta (REBOA), used to temporize noncom- ment facility is associated with a greater than 98%
pressible and junctional hemorrhage, may be deployable overall survival. [“A basic characteristic of organizing
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to the forward environment. Our hypothesis was that modern health services support is the distribution of
nonsurgeon physicians and high-level military medical medical resources and capabilities to facilities at various
technicians would be able to learn the theory and inser- levels of command, diverse locations, and progressive
tion of REBOA. Methods: US Army Special Operations capabilities. This is referred to as the four roles of care
Command medical personnel without prior endovascu- (Roles 1–4).” Role 1 is point of injury care; Role 2 is
lar experience were included. All participants received characterized by basic primary care capabilities and, if
didactic instruction of the Basic Endovascular Skills for augmented can potentially provide surgical capabilities;
Trauma Course together, with individual evaluation of Role 3 is characterized by full surgical and short-term
™
technical skills. A pretest and a posttest were adminis- intensive care unit capabilities. ]
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tered to assess comprehension. Results: Four members
of US Army Special Operations Command—two non- During the first 10 years of the conflict in the Middle
surgeon physicians, one physician assistant, and one East, 90.9% of potentially survivable causes of death
Special Operations Combat Medic—were included. among US military casualties were hemorrhage, of
REBOA procedural times moving from trial 1 to trial 6 which most were truncal (67.3%). The Military Health
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decreased significantly from 186 ± 18.7 seconds to 83 ± System Research Symposium of 2015 highlighted a
10.3 seconds (p < .0001). All participants demonstrated change in the goals of combat casualty care innovation
safe REBOA insertion and verbalized the indications going forward because of evolving areas of operation,
for REBOA insertion and removal through all trials. All calling on researchers to “. . . innovate for scenarios in
five procedural tasks were performed correctly by each which level 2 and 3 care is performed aboard transport
participant. Comprehension and knowledge between the vehicles or within local structures of opportunity . . .
pretest and posttest improved significantly from 67.6 ± field care may be prolonged, lasting for days or even
7.3% to 81.3 ± 8.1% (p = .039). Conclusion: This study weeks. . . .” Although efforts to push forward resusci-
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demonstrates that nonsurgeon and nonphysician provid- tation adjuncts into the hands of prehospital providers
ers can learn the steps required for REBOA after arte- are already underway, most of the currently available
rial access is established. Although insertion is relatively interventions will provide little benefit in the setting of
straightforward, the inability to gain arterial access per- major vascular or solid organ injuries. Current hemor-
cutaneously is prohibitive in providers without a surgical rhage control strategies are either impractical or impos-
skillset and should be the focus of further training. sible, representing a major gap in the ability to meet
these goals for resource-constrained environments.
Keywords: REBOA; resuscitative endovascular balloon oc-
clusion of the aorta; training; virtual reality simulation; junc- Major sources of potentially survivable hemorrhage
tional hemorrhage; noncompressible torso hemorrhage are noncompressible torso hemorrhage and junctional
hemorrhage. These conditions are classically temporized
with gravely morbid operative interventions such as
thoracotomy or laparotomy, with limited practicality
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Introduction
before arrival to a medical treatment facility. This has ne-
The continuous conflict of the last 15 years in the Mid- cessitated the development of forward deployable tech-
dle East has led to an unprecedented honing of the medi- niques for hemorrhage control by physicians and first
cal evacuation and treatment systems of the US military responders. A technique of inserting an endovascular

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