Page 49 - JSOM Winter 2018

The indications listed above are designed to rule out intratho- e. All REBOA in TCCC is Zone 1, since intra-abdominal
racic bleeding and hemopericardium that might be worsened hemorrhage originating above the aortic bifurcation
by Zone 1 REBOA. In discussing REBOA in a pending paper, cannot be definitively ruled out by a negative FAST
King notes that: “The major principle of reasonably excluding exam.
hemorrhage in any cavity proximal to proposed balloon occlu- f. Once the casualty has been determined to meet the cri-
sion is of paramount importance. Occlusion distal to a vascular teria for REBOA, the procedure should be undertaken
injury may result in rapid proximal blood loss and death.” 134 promptly, since further decreases in systolic blood pres-
sure will make common femoral artery access signifi-
There was some advocacy among our author group for Zone 3 cantly more difficult to obtain.
REBOA in carefully selected clinical settings when performed g. Placement of the balloon in aortic Zone 1 is guided by
by experienced providers for casualties who are believed to the markings on the ER-REBOA catheter. 25
have hemorrhage isolated to the pelvis or lower extremity h. Fully inflate the balloon in Zone 1. Start with 8–10mL of
junctional regions. The FAST exam has been found to be reli- any crystalloid IV fluid. Confirm full occlusion by not-
able in ruling out abdominal NCTH in some specific trauma ing that the contralateral femoral pulse is extinguished.
settings. Christian and her co-authors found a false negative i. If the contralateral femoral pulse is still present, add 2
rate of only 2% for the FAST exam when used to evaluate more mL of IV fluid and recheck the pulse. Repeat un-
hemodynamically unstable patients with pelvic fractures. In til the pulse is extinguished or a maximum of 24mL of
135
such cases, if no immediate improvement is noted in the blood fluid has been used.
pressure or if there is recurrent hypotension, then the balloon j. Leave the balloon inflated for 15 minutes. The SBP
should be immediately advanced to the Zone 1 position. In should increase quickly and substantially after balloon
the prehospital combat setting, however, where there is often inflation when the bleeding site is distal to Zone 1.
injury caused by high-velocity projectiles or fragments, the re- k. After 15 minutes, slowly deflate the balloon completely
sults of a negative FAST exam are less definitive. There are over 30 seconds.
studies that have shown that a negative FAST exam does not l. Re-assess the casualty. If he or she has an SBP of
always exclude the presence of intra-abdominal hemorrhage 80mmHg or greater, leave the balloon deflated.
with certainty. 79,136,137 A second reason to favor Zone 1 REBOA m. Continue to monitor.
in the prehospital environment is that, for casualties with ab- n. If the SBP drops below 80mmHg, re-inflate the bal-
dominopelvic NCTH and shock, immediate hemodynamic loon and use either Option 1 or Option 2 as guidance
support is needed. Tibbits et al found that Zone 1 REBOA for further inflation while continuing whole blood
produced a significantly greater proximal mean arterial pres- resuscitation.
sure than Zone 3 REBOA—(127.9mmHg vs 53.4mmHg) in o. Balloon Inflation Timing—Option 1:
an animal model—and recommended that Zone 3 REBOA not As long as the periods of balloon deflation without SBP
be used for hypotensive patients. Lastly, the study by Can- dropping below 80mmHg continue to be 3 minutes or
138
tle et al described a case series of 402 patients who required longer, use 10-minute inflation periods followed by an-
an emergent trauma laparotomy at one trauma center. Based other deflation for as long as is tolerated (SBP remains
on the location of their bleeding sites, Zone 1 REBOA would 80mmHg or higher) out to a maximum of 120 minutes.
have been potentially helpful in controlling hemorrhage in 384 Continue resuscitation with whole blood.
(96%) of patients, whereas aortic occlusion in Zone 3 would p. Balloon Inflation Timing—Option 2:
have helped control bleeding in only 35 patients (9%). 76 If the casualty does not maintain an SBP of 80mmHg
or higher for at least 3 minutes after balloon deflation,
REBOA Procedure in ARC then re-inflate the balloon and use a maximum of 30
REBOA in TCCC Advanced Resuscitative Care will be done minutes total balloon inflation time. Continue resuscita-
in accordance with the current version of the REBOA CPG tion with whole blood.
posted on the Joint Trauma System website (presently the one q. If the casualty has stabilized (SBP remains above
dated 6 July 2017) with the following additional recommen- 80mmHg without balloon inflation) after the inflation
dations to make it more suitable for the TCCC setting: times specified above, but is more than 4 hours from
the care of a surgeon, remove the sheath and hold pres-
*TCCC-specific considerations: sure for 30 minutes with a junctional tourniquet or
a. Placement of REBOA should be done in consultation with Combat Gauze or another TCCC-recommended
with a surgeon at the receiving medical treatment facility hemostatic dressing. Evaluate for distal pulses in the
(MTF), if at all possible. This will both provide expert extremity.
assistance on the decision to use REBOA and alert the r. If the casualty has stabilized as noted above, but is
receiving MTF so that they can prepare for the casualty. within 4 hours of surgical care, leave the sheath in place,
b. Teams with an ARC capability should have a CoTCCC- and flush the side port every 15–30 minutes with 3mL
recommended junctional tourniquet available to control of IV fluid.
access site bleeding should that be encountered. 7 s. Document distal pulses frequently.
c. If the junctional tourniquet has already been used for t. Once REBOA has been performed, every effort should
another casualty, 30 minutes of direct pressure with again be made to communicate with the surgeon who
Combat Gauze or another TCCC-recommended he- will be receiving the casualty and obtain his or her rec-
mostatic dressing should be used to control access site ommendations for subsequent management.
bleeding. u. Document all aspects of the REBOA procedure.
d. Ketamine can be used for procedural analgesia and
sedation. Opioids should be avoided in hypotensive The challenge in using Zone 1 REBOA for temporary con-
casualties. 34 trol of NCTH below the diaphragm is to effectively control or

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