Page 37 - JSOM Spring 2018

Bringing Resuscitative Endovascular Balloon Occlusion of the
Aorta (REBOA) Closer to the Point of Injury

A Simulation Study

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Jason D. Pasley, DO ; William A. Teeter, MD ; William B. Gamble, MD ,
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Philip Wasicek, MD ; Anna N. Romagnoli, MD ; Amelia M. Pasley, DO ;
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Thomas M. Scalea, MD ; Megan L. Brenner, MD 8
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ABSTRACT
Background: The management of noncompressible torso Keywords: hemorrhage control; independent duty medical
hemorrhage remains a significant issue at the point of injury. technician; resuscitative endovascular balloon occlusion of
Resuscitative endovascular balloon occlusion of the aorta the aorta; REBOA
(REBOA) has been used in the hospital to control bleeding
and bridge patients to definitive surgery. Smaller delivery sys-
tems and wirefree devices may be used more easily at the point Introduction
of injury by nonphysician providers. We investigated whether
independent duty military medical technicians (IDMTs) could Nearly two decades of global military conflict have shown
learn and perform REBOA correctly and rapidly as assessed by the magnitude of potentially preventable battlefield deaths
simulation. Methods: US Air Force IDMTs without prior en- from extremity and torso hemorrhage. These patients died
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dovascular experience were included. All participants received of their injuries before ever reaching a surgeon. Advances
didactic instruction and evaluation of technical skills. Proce- in tactical combat casualty care have improved hemorrhage
dural times and pretest/posttest examinations were adminis- control in the military prehospital care arena, specifically
tered after completion of all trials. The Likert scale was used with hemostatic gauze, as well as purpose-derived extremity
to subjectively assess confidence before and after instruction. and junctional tourniquets, and these are becoming a main-
Results: Eleven IDMTs were enrolled. There was a significant stay in nonmilitary, prehospital emergency medical services
decrease in procedural times from trials 1 to 6. Overall proce- worldwide. Extremity tourniquets have shown significant im-
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dural time (± standard deviation) decreased from 147.7 ± 27.4 provements in decreasing exsanguination on the battlefield.
seconds to 64 ± 8.9 seconds (p < .001). There was a mean im- However, currently, there are limited adjuncts available to
provement of 83.7 ± 24.6 seconds from the first to sixth trial the prehospital medic for noncompressible torso hemorrhage
(p < .001). All participants demonstrated correct placement of (NCTH).
the sheath, measurement and placement of the catheter, and
inflation of the balloon throughout all trials (100%). There Resuscitative endovascular balloon occlusion of the aorta
was significant improvement in comprehension and knowl- (REBOA) temporizes noncompressible torso and junctional
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edge between the pretest and posttest; average performance hemorrhage in select patients in the hospital. The advent of
improved significantly from 36.4.6% ± 12.3% to 71.1% ± smaller delivery systems and wirefree devices may enhance
8.5% (p < .001). Subjectively, all 11 participants noted signifi- the ability of nonphysician providers to use this technology
cant improvement in confidence from 1.2 to 4.1 out of 5 on more easily at, or near, the point of injury. With limited field
the Likert scale (p < .001). Conclusion: Technology for aortic supplies and, often, little or no blood products during some
occlusion has advanced to provide smaller, wirefree devices, military operations, proximal hemorrhage control with a de-
making field deployment more feasible. IDMTs can learn the vice could stabilize a patient in an austere environment for
steps required for REBOA and perform the procedure accu- transfer to a higher level of care with additional resources. In
rately and rapidly, as assessed by simulation. Arterial access is the current conflicts, REBOA has been inflated successfully for
a challenge in the ability to perform REBOA and should be a hemorrhage control in a building of opportunity, stabilizing
focus of further training to promote this procedure closer to casualties for the operating room but not in a true “prehospi-
the point of injury. tal” emergency medical services setting. 4
*Address correspondence to RA Cowley Shock Trauma Center, University of Maryland, 22 South Greene St, T4M14, Baltimore, MD 21201;
or jpasley@umm.edu
1 LT COL Pasley, MC, USAF, serves as director of Physician Education for the Baltimore Center for the Sustainment of Trauma and Readiness
Skills. He is an assistant professor of surgery at the RA Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD.
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2 Dr Teeter is a resident in the Department of Emergency Medicine at University of North Carolina, Chapel Hill, Chapel Hill, NC. CPT Gamble
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is a resident in the Department of Surgery at Walter Reed National Military Medical Center in Bethesda, MD. Dr Wasicek is a resident in the
Department of Surgery at University of Maryland Medical Center. CPT Romagnoli is a resident in the Department of Surgery at Walter Reed
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National Military Medical Center. Dr Pasley is an assistant professor of surgery at the RA Cowley Shock Trauma Center, University of Maryland
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Medical Center, and a staff physician at the Baltimore Department of Veterans Affairs in the department of surgery and critical care. Dr Scalea
is the physician in chief of the RA Cowley Shock Trauma Center. He serves as the Honorable Senator Francis X. Kelly Distinguished Professor
in Trauma Director, Program in Trauma at the University of Maryland. Dr Brenner is an associate professor of surgery at the RA Cowley Shock
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Trauma Center, University of Maryland Medical Center. She is board certified in vascular surgery, general surgery, and surgical critical care.
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