Page 142 - JSOM Fall 2019

ships, there is the risk of a fatal hemolytic reaction from an Ischemia–reperfusion injury after Zone 1 occlusion is the lim-
ABO mismatch. iting factor for this procedure and we must seek ways to ex-
tend the time for which this technique can be used to control
ARC also emphasizes the need to identify casualties who are in NCTH. Potential strategies include pharmacotherapy (Ca 2+
shock BEFORE they decompensate and become hypotensive. and bicarbonate), intermittent REBOA, and partial REBOA.
This is accomplished through the use of point-of-care lactate Zone 3 REBOA is not rec ommended in ARC because it is
testing. The indications for whole blood transfusion in ARC difficult to completely exclude the possibility of abdominal
are as follows:
bleeding sites below the diaphragm but above the bifurcation
– Casualty has known prior external hemorrhage (even if with only a FAST exam, and because the increase in proximal
that hemorrhage is now controlled) or suspected non- systolic blood pressure is more pronounced when aortic occlu-
compressible torso hemorrhage sion is performed in Zone 1 compared with Zone 3.
AND
– Systolic blood pressure (SBP) is less than 90mmHg Partial REBOA is not recommended in ARC at this time be-
OR cause con trolling the degree of partial aortic occlusion and the
– Point of Injury lactate is 4mmol/L or greater volume of distal blood flow with precision is not feasible in the
far-forward environment with the current state of technology.
The second pillar of ARC is far-forward Zone 1 REBOA. For Dr Martin conducted a study that examined survival and
casualties in shock whose blood pressure has not responded end-organ function comparing complete REBOA and inter-
to the first unit of transfused whole blood AND who have mittent REBOA in swine. Mean survival in control animals
had bilateral chest tubes inserted with no finding of significant with no REBOA was 15 minutes. With full REBOA for 60
hemothorax AND a cardiac ultrasound performed without ev- minutes, survival was 63 minutes – the animals died a mean
idence of hemopericardium – Zone 1 REBOA can effectively of 3 minutes after the balloon was deflated. With intermittent
stop abdominopelvic NCTH for a limited period of time. REBOA, there was 100% survival out to the end of the study
Thirty minutes of aortic occlusion is considered safe in Zone period at 120 minutes. Survival, lactate, and bowel ischemia
1 REBOA – and research done by COL Matt Martin’s team data indicated that intermittent REBOA can support trauma
at the Madigan Army Medical Center has shown in a lethal victims for extended periods with limited reperfusion injury.
large animal bleeding model that that the use of a programmed Both pressure-based and time-based intermittent REBOA
intermittency occlusion schedule resulted in 100% survival for techniques are feasible and effective. Time-based REBOA may
the 120-minute study period. A modification to the Madigan be the better option for ARC.
intermittency schedule proposed by Col Todd Rasmussen*
calls for the balloon to remain deflated if systolic blood pres- 16. TCCC in the Maritime Environment:
sure does not fall below 80mmHg. The ARC recommenda- CAPT Christopher Kurtz – Deputy Chief for Fleet
tions for REBOA intermittent balloon inflation therefore may Operations – Navy Bureau of Medicine and Surgery
allow the safe aortic occlusion time to be extended by a factor
of 4 – while still minimizing the risk of reperfusion injury – The Committee of Chiefs of Military Medical Services
when allowed by the casualty’s clinical condition. ( COMEDS) is NATO’s senior medical body, reporting to the
NATO Military Committee. It is composed of the Surgeons Gen-
In situations where whole blood and REBOA are indicated, eral of the allied nations and the senior medical advisers within
MINUTES MATTER! Many patients in shock from NCTH NATO’s command structure. COMEDS acts as the central point
during the prehospital phase of care will die before their for the development and coordination of common standards and
“Golden Hour” has elapsed if the measures recommended by for providing medical advice to the Military Committee.
ARC are not undertaken.
Within COMEDS, the Medical Naval Panel (MedNP) ad-
ARC requires a team – the combination of whole blood trans- dresses issues in maritime medicine. In 2018, MedNP tasked
fusion and Zone 1 REBOA cannot be effectively performed by its Subpanel 5 to explore options for TCCC in the maritime
an individual. Early common femoral artery access is an essen- environment. Subpanel 5 is developing a Maritime Module
tial first step in REBOA. This early access does not obligate (phases and scenarios) to be incorporated into the official
subsequent REBOA, but it increases the likelihood of success TCCC curriculum and is seeking CoTCCC collaboration.
in that it is far easier to gain common femoral artery access Subpanel 5 would like to present its work (see Enclosure 2)
BEFORE the patient has become hypotensive. to the CoTCCC for endorsement of its work on phases and
hopes a CoTCCC liaison will be able to participate in its Fall
15. Extending the Golden Hour for Zone 1 REBOA on the 2019 meeting in Rome to develop maritime scenarios. Their
Battlefield: Intermittent, Partial, and Beyond: Dr Matthew final product is due to MedNP in the spring of 2020.
Martin – Scripps Institute Medical Center, San Diego
17. ARC Rollout: Col Joseph Dubose –
Dr Martin began with case reports illustrating the utility and
difficulties associated with REBOA. Director, C-STARS Baltimore
With the advent of limb and junctional tourniquets, non-com- The Joint Special Operations Command and the 160th Special
pressible torso hemorrhage now accounts for the majority of Operations Aviation Regiment have implemented ARC train-
preventable deaths from hemorrhage. REBOA is a great ad- ing for their surgical and far-forward resuscitation teams. The
vance and can save lives, but it is also a procedure that entails initial JSOC training was held in October 2018 at Fort Bragg,
some morbidity and the potential for mortality. NC.

*F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland and Department of Surgery,
Walter Reed National Military Medical Center, Bethesda, MD.

140 | JSOM Volume 19, Edition 3 / Fall 2019