Page 38 - JSOM Spring 2020

Successful Placement of REBOA in a
Rotary Wing Platform Within a Combat Theater

Novel Indication for Partial Aortic Occlusion

S. R. Brown*; D. H. Reed; P. Thomas; G. C. Simpson; J. D. Ritchie

ABSTRACT
Resuscitative endovascular balloon occlusion of the aorta femoral vein. After two doses of epinephrine (1mg), infusion
(REBOA) is used to augment resuscitation in patients with of 1 unit of packed red blood cells (PRBCs), and 2 units of
noncompressible torso hemorrhage, which is a leading cause low titer O whole blood (LTOWB), the patient had return
of death on the battlefield. However, the implementation of of spontaneous circulation (ROSC). At this time, the exit
REBOA has resulted in considerable debate within the mili- wound began to hemorrhage and was packed with combat
tary medical community. We present a case of the first success- gauze and redressed with an ACE wrap to obtain adequate
ful placement of an REBOA by a small surgical team within a hemostasis. Left femoral arterial access was then obtained un-
mobile rotary wing platform. der ultrasound guidance using a 5Fr micropuncture catheter.
This attempt was interrupted when a loss of femoral pulse
Keywords: REBOA; surgery; head injury; trauma; small surgi- under direct ultrasound visualization was noted. The loss of
cal team; resuscitation perfusion was confirmed with lack of carotid pulse. A second
round of chest compressions was started and a third dose of
epinephrine along with continued resuscitation (LTOWB),
which resulted in ROSC within a short time (<2 minutes).
Introduction
Once arterial access was obtained, the micropuncture cath-
Noncompressible torso hemorrhage (NCTH) is a leading eter was upsized to a 7Fr sheath. The ER-REBOA was pre-
1
cause of death on the battlefield. REBOA to augment resus- pared and inserted without difficulty into zone I (46cm) and
citation in patients with NCTH has gained significant trac- secured with a halo chest seal. The balloon was left deflated
2,3
tion in civilian trauma centers over the past several years. at this time given the return of vital signs and a blood pressure
Additionally, there have been several case reports and a case of 110/60mmHg. Resuscitation was continued with LTOWB
series published illustrating the positive impact of REBOA uti- and liquid plasma (LP).
lization in the combat environment. These results have led
4–6
to debate within the military medical community as to where Given the patient’s head injury and need for urgent neurosur-
in the evacuation chain this technique should be used and the gical intervention, the decision was made to transload the pa-
level of training necessary for safe and effective utilization. tient to a fixed-wing (FW) platform for rapid transport to the
This case demonstrates placement of a REBOA catheter on closest Role III. The patient remained hemodynamically sta-
a rotary wing (RW) platform with partial aortic occlusion ble throughout the remainder of the RW flight and transition
(PAO) for the immediate treatment of hemorrhage shock due between aircraft. However, during take-off the patient had a
to supradiaphragmatic wounds. significant drop in systolic blood pressure (SBP) from 135 to
70mmHg and in mean arterial pressure (MAP) from 75 to 40
mmHg, and the carotid pulse became thready. Partial aortic
Case Presentation
occlusion (PAO) with 3mL of saline was performed with an
Our small surgical team includes two physicians (emergency immediate improvement in SBP to 135mmhg and MAP to
medicine physician and surgeon) who have both completed 80mmHg. Once cruising altitude was reached and the patient
the Basic Endovascular Skills for Trauma (BEST) course. The remained stable, the balloon was deflated in 1mL intervals
team was notified of a US casualty with a gunshot wound to with a total partial aortic occlusion (PAO) time of 11 minutes.
the head and moved via RW platform to the casualty. Arriving The patient remained hemodynamically stable after balloon
approximately 27 minutes from the time of injury, the primary deflation until the aircraft started the descent, at which time
survey demonstrated a cricothyroidotomy in place (previous the patient again experienced a drop in SBP. A second PAO
right humeral IO was lost during transfer of patient), thready was performed with 3mL of saline with rapid improvement
carotid pulse, hypoactive cardiac activity on extended focused in SBP (130/70/140; PAO time 12 minutes). At the Role III, a
assessment with sonography in trauma (E-FAST), and Glasgow chest radiograph (Figure 1) demonstrated appropriate Zone 1
Coma Scale score 3T. The patient had an entrance wound to REBOA placement. The patient underwent a decompressive
the right face and an exit wound in the right occipital region. craniectomy. Over the next 24 hours, the patient remained he-
Once a secured airway was confirmed, the patient lost vital modynamically stable but had deterioration of his condition
signs and chest compressions were initiated. Central venous to include right parietal, temporal, and occipital lobe infarc-
access was obtained with an 8.5Fr Cordis catheter in the right tion with increased intraparenchymal hemorrhage (Figure 2).
*Correspondence to shaun.r.brown14.mil@mail.mil
All authors are from the Department of Surgery, Womack Army Medical Center.

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