Page 96 - Journal of Special Operations Medicine - Spring 2017

Figure 2 Algorithm for the management of profound As with all medical procedures, the risks need to be
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shock. A/P/E, abdomen/pelvis/extremity; CPR, cardiopulmo- weighed against the benefits. Patient and operator se-
nary resuscitation; FAST, focused assessment with sono graphy lection are key to avoiding iatrogenic injury. REBOA
in trauma; Fx, fracture; REBOA, resuscitative endovascular has a demonstrated role in the resuscitation of trauma
balloon occlusion of the aorta; REBOA I, placement of aor- patients in hemorrhagic shock and may have wider ap-
tic balloon in the thoracic aorta (2–8cm above the xiphoid); plications in the military and prehospital arenas. This
REBOA III, placement of aortic balloon directly above the is not a procedure that should be attempted by a single
aortic bifurcation (1–2cm above the umbilicus); ROSC, return
of spontaneous circulation; SBP, systolic blood pressure. provider; it should be performed in a team environment.
These patients will likely require advanced airway man-
agement, analgesia and anesthesia, blood-product resus-
citation, and transport to a surgeon that will facilitate
a balloon occlusion time of less than 60 minutes. Due
to hemorrhagic shock, these patients may demonstrate
collapsed vasculature, contributing to difficult arterial
cannulation. Providers must be facile with ultrasound-
guided vascular access procedures or have experience
with vascular cut-down procedures to place the catheter
in a timely fashion.

This technique deserves further investigation because
zone III REBOA could be performed by advanced pre-
hospital surgical and resuscitative teams today with ap-
propriate education and patient selection. Appropriate
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Figure 3 Traumatic arrest algorithm. A/P/E, abdomen/pel- provider experience is necessary. It is imperative that
vis/extremity; CPR, cardiopulmonary resuscitation; EKG, elec- anyone attempting to use REBOA be facile with central
trocardiogram; FAST, focused assessment with sonography in venous or arterial access, the Seldinger technique, and ul-
trauma; OR, operating room; REBOA, resuscitative endovas-
cular balloon occlusion of the aorta; REBOA I, placement of trasound use. Abbreviated training courses could lead to
aortic balloon in the thoracic aorta (2–8cm above the xiphoid). provider target fixation, with multiple attempts leading
to a prolonged procedure, failed access, or venous access.
The American College of Emergency Physicians recom-
mends a minimum of 10, but preferably 25, procedures
in clinical situations for providers already competent in
central-line placement for credentialing in ultrasound-
guided placement. The time spent by an inexperienced
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provider attempting to cannulate the CFA would be bet-
ter allocated to adequate resuscitation and evacuation.

Providers must also remember that this does not substitute
for rapid, definitive surgical correction, and recent studies
demonstrated increased mortality with balloon inflation
times longer than 30 minutes. This is not a technique
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that will extend the golden hour and obviate the need for
repair. Zone I REBOA is the endovascular equivalent surgical coverage, and it may lead to increased mortality
to resuscitative thoracotomy (with cross clamping of with improper patient or provider selection.
the aorta) with overall less morbidity. Appropriate pa-
tient selection is critical. Resuscitative thoracotomy is In summary, REBOA has a role in Combat medi-
still recommended in the decompensating patient or in cine resuscitation. Multiple studies demonstrate
the event of acute loss of vital signs with penetrating noncompressible hemorrhage as the leading cause of
trauma. However, early intervention and placement of preventable death on the battlefield. 16,17 Patient selec-
an arterial sheath could facilitate REBOA instead of tion is critically important. Patients who may benefit
periarrest thoracotomy. The patient with noncompress- from prehospital battlefield REBOA are those with un-
ible hemorrhage with adequate vital signs with blood- controlled pelvic or inguinal hemorrhage that are not
product resuscitation could benefit from CFA access in responding to adequate blood-product resuscitation and
anticipation of the need for proximal aortic control. A may not survive to surgical control. Many techniques ex-
balloon could be positioned and inflated before loss of ist for proximal arterial control, including thoracotomy,
vital signs to avoid the morbidity or thoracotomy. 13 laparotomy, and advanced vascular access techniques.

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