Page 36 - JSOM Spring 2018

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Introduction

David R. King, MD

esuscitative endovascular balloon occlusion of the aorta training for REBOA must involve not only the technical
R(REBOA) is quickly becoming fashionable among civil- skills for the REBOA insertion but also the ability to triage
ian and military medical providers. Balloon occlusion of the all cavities appropriately before REBOA use. Perhaps other
aorta is not new to aneurysm management; however, its use technology will evolve to simplify how a provider will exclude
in trauma remains relatively unstudied and outcomes from hemorrhage in compartments proximal to the proposed bal-
REBOA remain entirely unclear. Training, although certainly loon occlusion site.
important for performance of the skill set, should not be con-
fused with appropriateness of the intervention: Just because One additional limitation may be aortic access. Although
one can perform REBOA does not mean one should perform percutaneous access in the groin may be straightforward in
REBOA. This is true for inhospital use, but it is especially poi- a patient with normal hemodynamics, gaining access in a hy-
gnant for the prehospital environment, where no science exists potensive patient, perhaps without palpable femoral pulses, is
on the topic. challenging. Inadvertent venous puncture is common, and ve-
nous cannulation with REBOA has been reported. Balloon oc-
One of the biggest hurdles for prehospital REBOA is the clear- clusion of the vena cava via unrecognized venous cannulation
ance of the supradiaphragmatic compartment. Unfortunately, may result in precipitous loss of preload and sudden cardiac
the surface anatomy of penetrating wounds does not predict arrest. Open cannulation is possible, but this may represent
the cavity in which hemorrhage may be occurring. The pleural another fragile skill set that will require ongoing sustainment
spaces and the pericardium must be triaged before REBOA is training.
used. Balloon occlusion distal to a vascular injury will likely
result in impressive exsanguination and rapid death. REBOA for trauma is in its infancy. Multiple inhospital reg-
istries and published experiences exist; however, solid science
Theoretically, prehospital cavitary triage of the supradia- is still lacking. The use of REBOA in the prehospital environ-
phragmatic compartments (i.e., the pleural spaces and the ment remains unexplored. Ongoing research hopefully will
pericardium) can be accomplished by using ultrasonography, guide providers in making evidenced-based decisions. In the
but the ultrasound skills of the provider must be absolutely meantime, we should continue to select our patients to un-
reliable, sustainable, and robust enough to avoid, for exam- dergo REBOA very carefully and avoid cavalier decisions not
ple, a zone-1 balloon occlusion in a patient with a pulmonary based in science.
parenchymal injury resulting in hemothorax. Similarly, if a
provider is contemplating a zone-3 balloon occlusion for a First, do no harm.
complex pelvic fracture, the provider must establish presence Respectfully,
of a complex pelvic fracture (it is unclear how one might ac-
complish this in the prehospital environment, because physical David R. King, MD, FACS
examination is wildly unreliable) and exclude not only supra- LTC, US Army
diaphragmatic hemorrhage but intra-abdominal hemorrhage Associate Professor of Surgery, Harvard Medical School
as well. A zone-3 occlusion in a patient with supramesocolic Massachusetts General Hospital
hemorrhage, such as a splenic laceration, is likely a lethal Director, Fellowship Program in Trauma,
intervention. Acute Care Surgery, and Surgical Critical Care
Director, Trauma Research Program
Thus, clearly a provider’s ultrasound skills are likely more Boston, Massachusetts
important than the provider’s REBOA skills. Consequently,

In addition to the current two articles on REBOA that follow,
the JSOM has published other studies in the past. Their abstracts follow the articles.

32