Page 41 - JSOM Spring 2018

Feasibility and Proposed Training Pathway for Austere Application of
Resuscitative Balloon Occlusion of the Aorta

1,2
Elliot M. Ross, MD, MPH *; Theodore T. Redman, MD, MPH 3

ABSTRACT
Background: Noncompressible junctional and truncal hemor- Introduction
rhage remains a significant cause of combat casualty death.
Resuscitative endovascular balloon occlusion of the aorta Noncompressible junctional and truncal hemorrhage remains
( REBOA) is an effective treatment for many junctional and a significant cause of combat casualty death. Gap analysis of
noncompressible hemorrhages. The current hospital standard combat deaths shows that nearly 87% of patients died of un-
1
for time of placement of REBOA is approximately 6 minutes. controlled hemorrhage Resuscitative endovascular balloon
This study examined the training process and the ability of occlusion of the aorta (REBOA) is an effective treatment for
2–9
nonsurgical physicians to apply REBOA therapy in an austere many junctional and noncompressible hemorrhages. An
field environment. Methods: This was a skill acquisition and analysis of a UK combat hospital demonstrated 20% of deaths
feasibility study. The participants for this experiment were two might have benefitted from REBOA therapy and of those who
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board-certified military emergency medicine physicians with no died, 83% died before reaching a medical treatment facility.
prior endovascular surgery exposure. Both providers attended This finding suggests moving the therapy closer to the point of
two nationally recognized REBOA courses for training. A per- injury may have the most significant effect on casualty deaths.
fused cadaver model was developed for the study. Each provider
then performed REBOA during different phases of prehospital Previous REBOA techniques required placing large-diameter
care. Time points were recorded for each procedure. Results: vascular sheaths that would necessitate vascular repair and of-
11,12
There were 28 REBOA catheter placement attempts in 14 per- ten required arterial cutdown to access the femoral artery.
fused cadaver models in the nonhospital setting: eight place- The newer generation of REBOA catheters are smaller and
3,13–16
ments in a field setting, eight placements in a static ambulance, can be placed through smaller introducer sheaths. This
four placements in a moving ambulance, and eight placements new generation makes placement by emergency medicine,
inflight on a UH-60 aircraft. No statistically significant differ- critical care, and other nonsurgical providers a reasonable
ences with regard to balloon inflation time were found between possibility.
the two providers, the side where the catheter was placed, or
individual cadaver models. Successful placement was accom- The physician-based London Helicopter Emergency Medi-
plished in 85.7% of the models. Percutaneous access was suc- cal System (HEMS) has developed a training program for
cessful 53.6% of the time. The overall average time for REBOA REBOA placement by their prehospitalists. They have success-
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placement was 543 seconds (i.e., approximately 9 minutes; fully placed REBOA catheters in the prehospital setting. The
median, 439 seconds; 95% confidence interval [CI], 429–657) first application took approximately 25 minutes in the field
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and the average placement time for percutaneous catheters was to complete. The current hospital standard for placement of
376 seconds (i.e., 6.3 minutes; 95% CI, 311–44 seconds) ver- REBOA is approximately 6–7 minutes. This study examined
sus those requiring vascular cutdown (821 seconds; 95% CI, the training process and the ability of nonsurgical physicians
655–986). Importantly, the time from the decision to convert to apply REBOA therapy in an austere field environment
to open cutdown until REBOA placement was 455 seconds and whether the application times can approach the hospital
(95% CI, 285–625). Conclusion: This study demonstrated that, standard.
with proper training, nonsurgical providers can properly place
REBOA catheters in austere prehospital settings at speeds and
with effectiveness similar to those in the hospital setting. Methods
Study Design and Setting
Keywords: austere environment; noncompressible hemor- This was a skill acquisition and feasibility study. It was re-
rhage; resuscitative endovascular balloon occlusion of the viewed by the University of Texas Health Science Center at
aorta; battlefield REBOA; combat resuscitation team; pre- San Antonio Institutional Review Board and meets require-
hospital REBOA; damage control resuscitation; helicopter ments for human cadaver research. This project was also
REBOA; en route care REBOA reviewed by the Brooke Army Medical Center Institutional
Review Board and complies with the Army Policy for the

*Address correspondence to s5eross@yahoo.com
1 Drs Ross and Redman are from the University of Texas Health Science Center San Antonio, Office of the Medical Director, San Antonio, TX;
the San Antonio Uniformed Services Health Education Consortium, JBSA Fort Sam Houston, TX; and the Prehospital Research and Innovation
in Military and Expeditionary Environments (PRIME2) Research Group. In addition, CDR Ross, MC USN, is the Navy Medicine West EMS
2
3
Medical Director, USNH Guam. LTC Redman is the Regimental Surgeon, 160th Special Operations Aviation Regiment, Ft. Campbell, KY.
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