Page 50 - JSOM Winter 2018

minimize abdominopelvic hemorrhage while also minimizing deflation. At autopsy, acute tubular necrosis was seen in all of
the negative consequences of the ischemia sustained in the tis- the REBOA animals that died. 141
sues below the occlusion.
Kheirabadi noted that 50% of the spontaneously breathing
The intermittent REBOA protocol above is based largely on animals in his study died from cardiopulmonary arrest shortly
the recent publication by Kuckelman and his colleagues from after AAJT removal following 2 hours of aortic occlusion just
the research laboratory at Madigan Army Medical center. In above the bifurcation. 78
a swine model of abdominopelvic NCTH that was 100% le-
thal in untreated control animals (n=7), intermittent Zone 1 In contrast, the intermittent Zone 1 REBOA approach stud-
REBOA techniques (both time and pressure-based) resulted in ied by Kuckelman produced 100% survival out to 120 min-
100% survival in 16 animals for the 120-minute study period. utes, demonstrating that intermittent Zone 1 REBOA can be
In contrast, all 5 animals treated with full occlusion REBOA performed with good results and less risk of ischemic compli-
survived the 60 minute occlusion period, but died shortly after cations than application of the AAJT for the same period of
the balloon was deflated. Mean time to death was 63 min- time. The modification suggested by Rasmussen builds on this
utes—or 3 minutes after balloon deflation. The Intermittent work—and in theory increases the safety of the procedure—
80
Zone 1 REBOA protocol proposed above uses the time-based by calling for the balloon to remain deflated after the initial
intermittent REBOA technique developed at Madigan and de- 15-minute inflation—unless it is clinically needed, as indicated
scribed in the Kuckelman study in conjunction with a modi- by the casualty’s SBP dropping below 80mmHg after balloon
fication proposed by Col Todd Rasmussen of the Uniformed deflation.
Services University: if the casualty remains stable after the bal-
loon is deflated following the initial 15-minute inflation, the Advanced Resuscitative Care—A Team Effort
balloon is left in place but not re-inflated unless SBP drops be- TCCC has in the past been focused on interventions that can
low 80mmHg again. There is at present no data on the safety be accomplished by a single combat medical provider working
and efficacy of this intermittent REBOA technique beyond the out of his or her aid bag. To restate the point made previously,
120 minutes study period used in the Kuckelman paper. ARC is NOT that. REBOA is not proposed as an addition
to the standard skill set of combat unit physicians, physician
There is limited evidence to support recommendations for a assistants, or combat medical personnel unless they are part
specific safe maximum time for Zone 1 aortic occlusion, how- of a team that has been specifically designated and designed
ever most authors agree that an occlusion time of less than to have an ARC capability. REBOA should be performed by
30 minutes is safe. King states in a pending paper that “Ab- these designated, trained, and equipped teams. The individ-
dominal visceral ischemia limits occlusion time to less than ual who actually performs the procedure should be skilled at
30 minutes.” The current JTS CPG specifies that balloon arterial access and ultrasound; should have been trained at
139
inflation in Zone 1 be limited to 30-60 minutes. In a survey an approved REBOA training course; should have demon-
25
of participants in the International Endovascular and Hybrid strated the ability to successfully accomplish this procedure;
Trauma and Bleeding Management Symposium, DeSoucy and should be trained as well in the ARC intermittent Zone 1
found that, of 86 respondents to a post-conference survey, REBOA procedure that is specifically designed for the prehos-
35% stated that the maximum time for aortic occlusion in pital setting.
Zone 1 should be 30 minutes or less; 9% favored an occlusion
time of 45 minutes or less; 6% favored an occlusion time of The optimal composition of teams performing ARC remains
60 minutes or less; 19% believed that there should be no limit to be determined, but Figure 4, discussed previously, outlines
if the patient remains unstable; and 31% believed that current the multiple tasks that must be performed rapidly in order to
available data is insufficient to provide a recommendation. 140 ensure that whole blood resuscitation and REBOA—if indi-
cated—can be undertaken without delay. Among the tasks
As noted previously, all 5 animals treated with full occlusion that will need to be performed are: ensuring an adequate air-
Zone 1 REBOA survived the 60 minute occlusion period, way, electronic monitoring of vital signs, establishing IV or
but died at a mean time of 3 minutes after the balloon was IO access, preparing and infusing blood products, performing
deflated. 80 EFAST and bilateral chest tubes, establishing common fem-
oral artery access, prepping the REBOA site, performing the
Reva and colleagues studied survival in sheep that underwent REBOA procedure, and recording the events that occur during
thoracic occlusion of the aorta for either 30 or 60 minutes. the resuscitation. Collectively these interventions and actions
Hemorrhagic shock was induced in 18 animals through 35% require a team of at least 3 or 4 individuals in order to be done
controlled hemorrhage accomplished over 30 min. The sheep quickly and efficiently.
were randomized into three groups: 60-minutes of REBOA
begun 30 minutes after the bleeding (60-REBOA); 30 minutes Although a Joint Statement from the American College of
of REBOA begun 60 minutes after the bleeding (30-REBOA); Surgeons and the American College of Emergency Physicians
and no-REBOA as controls (n-REBOA). Fluid resuscitation stated that REBOA use should be restricted to surgeons and
was accomplished with crystalloids and whole blood initiated emergency medicine physicians who have done a critical care
20 and 80 minutes after shock was induced. The duration of fellowship, this recommendation has been contested by
142
the study period was 24 hours with autopsies performed to other authors, including US military medical officers. (143,144)
evaluate organ damage. Twenty-four hour survival was noted Northern and colleagues noted that 7 of their 20 REBOA pro-
to be 0/6 in the 60-REBOA group; 5/6 in the 30- REBOA cedures were performed by Emergency Medicine (EM) physi-
group; and 4/6 in the control group (P = 0.002). As with the cians. 84,145 Matsumura and colleagues reported in a study of
Kuckelman study, there was no provision of critical care in- 142 REBOA procedures from 18 hospitals in Japan that 94%
terventions to mitigate reperfusion sequelae after balloon of REBOA procedures were performed by EM physicians. 101

48 | JSOM Volume 18, Edition 4 / Winter 2018