Page 56 - JSOM Winter 2018

methodology that facilitates and possibly automates this – How can virtual reality technology assist in REBOA
step and decreases the need for cutdowns to obtain femo- training?
ral access would be very useful. – How often should REBOA training be refreshed in or-
12. There is not good consensus about the use of REBOA in der to assure competency?
casualties with TBI. Hypotension has been shown to in- – How can the clinical experience with REBOA for ARC
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crease mortality in patients with moderate/severe TBI, but team members be optimized?
the large rise in blood pressure proximal to the inflated
Zone 1 REBOA balloon could potentially increase intracra- Additional ARC-Related Topics
nial hypertension and exacerbate intracranial hemorrhage. 21. Research attention should be directed towards better
Identification of which subsets of TBI might be helped or identification of which subsets of casualties will benefit
harmed by REBOA should be an area of investigation. the most from ARC, in particular, how to identify pa-
13. Optimization of REBOA balloon deflation technique tients who are experiencing life threatening noncompress-
offers the potential to mitigate the risk of post-deflation ible intra-cavitary hemorrhage, but who have not yet
hyperkalemia and acidosis. Studies examining this issue, decompensated into hemorrhagic shock. The Compen-
however, have reported that return of distal aortic flow as satory Reserve Measurement devices, better POI lactate
a factor of balloon volume removed was inconsistent in monitoring techniques, and vital-sign-based prediction
study animals. This topic deserves further investigation. algorithms all have promise in this area.
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14. REBOA is new to the prehospital phase of care. Careful 22. How can teams with an ARC capability be best utilized in
monitoring of outcomes achieved from these procedures combat operations to minimize the time from wounding
as well as any complications ensuing from its use should to initiating ARC and still maintain an acceptable risk
be accomplished by a focused JTS performance improve- level to the resuscitation team?
ment monitoring program. 23. What additional medications or hemostatic adjuncts would
15. ARC entails both whole blood resuscitation and REBOA offer the most benefit to casualty survival and should be
when the bleeding site is determined to be below the dia- used by ARC teams?
phragm. The effect on outcomes achieved by whole blood
resuscitation without REBOA is also a topic of research – Modified TXA dosing?
interest. A review of casualties for whom ARC is used – Calcium administration during/after REBOA?
may be able to help answer that question. Casualties with – Valproic acid?
NCTH and shock who are found to have intrathoracic – Fibrinogen?
bleeding on chest tube placement will not be candidates – Factor concentrate mixtures?
for REBOA, but they will continue to receive whole blood – Vasopressors?
resuscitation. Outcomes from this subset of patients – Naloxone?
should be reviewed to help determine the magnitude of – Hormones?
benefit obtained from whole blood resuscitation alone. – Others?
16. Smaller arterial catheters have been found to reduce the
risk of thrombotic complications associated with arterial 24. Improved methodology is still needed for all prehospi-
access. The feasibility of further decreases in the size of tal care documentation, but especially for documenting
the REBOA device from the current 7 Fr ER-REBOA care in ARC. Research in this area should include hands-
catheter to a 5 Fr or smaller device should be explored. free recording techniques, electronic transcription, bet-
17. Expert opinion varies with regard to how long the ter quality of voice-to-text transcription, automatic time
REBOA sheath should be left in place after the initial stamping technology, and better ability to both protect
procedure so that the balloon could be inflated again if the care documentation data and transmit it to subse-
needed. Additional techniques and technology to enable quent providers and the electronic health record.
longer periods of safe intra-arterial dwell time should be 25. What is the mortality in US military casualties who pres-
investigated. ent with shock and subsequently require an emergent lap-
18. Research evaluating current and future REBOA devices arotomy? The US military needs to conduct a counterpart
to validate their safety, performance, and any limitations study to the recent Harvin and Marsden studies in our
that would be encountered in-flight during the aeromedi- nation’s combat casualties.
cal evacuation and transport process should be conducted. 26. Care provided during ARC should be meticulously doc-
19. The emerging literature on REBOA contains studies with umented and reviewed in near-real-time for performance
variations in the bleeding models, resuscitation (timing, improvement purposes, but in addition to the PI process,
volumes, and types of fluids), post-deflation critical care examination of patient care and outcome data should be
provided to the animals, and other study methodologies. conducted under research protocols to better understand
An NCTH model that is standardized insofar as feasible the factors affecting casualty outcomes.
would be helpful in comparing studies. 27. Diligent performance improvement monitoring and sub-
sequent research into outcomes should also be conducted
for casualties who met the criteria for whole blood and
Training
20. Research is needed in many aspects of REBOA training, REBOA, but who did not receive these interventions.
to include: 28. Optimal target blood pressures using whole blood re-
suscitation during ARC should be a research topic. Con-
– Is training best accomplished with simulators, per- sideration should be given to both casualties with and
fused cadavers, or live tissue training? without TBI and to how best to incorporate the response
– How many successful REBOA procedures are needed to initial resuscitation and balloon deflation into subse-
to assure competency? quent resuscitation.

54 | JSOM Volume 18, Edition 4 / Winter 2018