Page 54 - JSOM Winter 2018

*NOTE: Use of non–FDA-compliant whole blood requires Combat Gauze or another TCCC-recommended he-
additional post-transfusion monitoring per DoD directives. mostatic dressing should be used to control access site
e. Continue resuscitation until an SBP of 80–90mmHg is bleeding.
present. d. Ketamine can be used for procedural analgesia and
f. If the casualty has an altered mental status due to sus- sedation. Opioids should be avoided in hypotensive
pected TBI, resuscitate as necessary to restore and main- casualties.
tain a target SBP of at least 90mmHg. e. All REBOA in TCCC is Zone 1, since intra-abdominal
g. During resuscitation, blood products should be warmed hemorrhage originating above the aortic bifurcation can-
using a fluid warmer and infused rapidly. not be definitively ruled out by a negative FAST exam.
h. As whole blood transfusion is being performed, con- f. Once the casualty has been determined to meet the cri-
sider obtaining early common femoral artery access so teria for REBOA, the procedure should be undertaken
that REBOA can be undertaken quickly after the first promptly, since further decreases in systolic blood pres-
unit of whole blood has been administered should the sure will make common femoral arterial access signifi-
casualty subsequently be found to meet the criteria for cantly more difficult to obtain.
REBOA. g. Placement of the balloon in aortic Zone 1 is guided by
the markings on the ER-REBOA catheter.
6. Indications for REBOA in ARC: h. Fully inflate the balloon in Zone 1. Start with 8–10mL of
*See Appendix B in the Joint Trauma System REBOA CPG: any crystalloid IV fluid. Confirm full occlusion by not-
“SBP < 90 with Transient or No Response to Initial ATLS Re- ing that the contralateral femoral pulse is extinguished.
suscitation.” (6 July 2017) i. If the contralateral femoral pulse is still present, add 2
more mL of IV fluid and recheck the pulse. Repeat un-
*TCCC-specific considerations: til the pulse is extinguished or a maximum of 24mL of
a. Relevant Tactical Field Care interventions (external fluid has been used.
hemorrhage control, pelvic binding, and TXA) have j. Leave the balloon inflated for 15 minutes. The SBP
been accomplished; should increase quickly and substantially after balloon
AND inflation when the bleeding site is distal to Zone 1.
b. Advanced monitoring (Electronic blood pressure mea- k. After 15 minutes, slowly deflate the balloon completely
surement) has been established; over 30 seconds.
AND l. Re-assess the casualty. If he or she has an SBP of
c. ARC resuscitation has been previously initiated with 80mmHg or greater, leave the balloon deflated.
whole blood if feasible or other blood products as noted m. Continue to monitor.
previously; n. If the SBP drops below 80mmHg, re-inflate the balloon
AND and use either Option 1 or Option 2 as guidance for
d. SBP remains < 90mmHg immediately after 1 unit of further inflation.
whole blood or 1 unit each of RBCs and plasma have o. Balloon Inflation Timing—Option 1:
been administered as quickly as possible; As long as the periods of balloon deflation without SBP
AND dropping below 80mmHg continue to be 3 minutes or
e. The Casualty has penetrating or severe blunt force longer, use 10-minute inflation periods followed by an-
injury to the abdomen or pelvis and a positive FAST other deflation out to a maximum of 120 minutes. Con-
exam or is judged to be at high risk for abdominopelvic tinue resuscitation with whole blood.
NCTH or is noted to have difficult-to-control junctional p. Balloon Inflation Timing—Option 2:
hemorrhage. If the casualty does not maintain an SBP of 80mmHg
AND or higher for at least 3 minutes after balloon deflation,
f. Intra-thoracic bleeding and cardiac tamponade have then re-inflate the balloon and use a maximum of 30
not been found on bilateral chest tube insertion and an minutes total balloon inflation time. Continue resuscita-
EFAST exam.
tion with whole blood.
q. If the casualty has stabilized (SBP remains above
7. REBOA Procedure in ARC 80mmHg without balloon inflation) after the inflation
*REBOA in TCCC Advanced Resuscitative Care will be done times specified above, but is more than 4 hours from
in accordance with the current version of the REBOA CPG the care of a surgeon, remove the sheath and hold pres-
posted on the Joint Trauma System website with the following sure for 30 minutes with a junctional tourniquet or
exceptions to make it more suitable for the TCCC setting:
with Combat Gauze or another TCCC-recommended
*TCCC-specific considerations: hemostatic dressing. Evaluate for distal pulses in the
a. Placement of REBOA should be done in consultation extremity.
with a surgeon at the receiving medical treatment fa- r. If the casualty has stabilized as noted above, but is
cility (MTF), if at all possible. This will both provide within 4 hours of surgical care, leave the sheath in place,
expert assistance on the decision to use REBOA and and flush the side port every 15–30 minutes with 3mL
alert the receiving MTF so that they can prepare for the of IV fluid.
casualty. s. Document distal pulses frequently.
b. Teams with an ARC capability should have a CoTCCC- t. Once REBOA has been performed, every effort should
recommended junctional tourniquet available to control again be made to communicate with the surgeon who
access site bleeding should that be encountered. will be receiving the casualty and obtain his or her rec-
c. If the junctional tourniquet has already been used for ommendations for subsequent management.
another casualty, 30 minutes of direct pressure with u. Document all aspects of the REBOA procedure.

52 | JSOM Volume 18, Edition 4 / Winter 2018