Page 87 - JSOM Spring 2020

Feasibility Study of Vascular Access and
REBOA Placement in Quick Response Team Firefighters

B. L. S. Borger van der Burg, MD, FEBVS *; S. M. Vrancken, MD ;
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T. T. C. F van Dongen, MD, PhD ; J. J. DuBose, MD, FACS ;
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M. W. Bowyer, MD, FACS, DMCC ; R. Hoencamp, MD, PhD, FEBVS, DMA 6

ABSTRACT

Background: Early hemorrhage control using resuscitative en- bleeding control include wound clamps, injectable hemostatic
dovascular balloon occlusion of the aorta (REBOA) can save sponges, pelvic circumferential stabilizers, resuscitative tho-
lives. This study was designed to evaluate the ability to train racotomy, intra-abdominal gas insufflation, junctional and
Quick Response Team Fire Fighters (QRT-FF) to gain percuta- truncal tourniquets, and resuscitative endovascular balloon
1
neous femoral artery access and place a REBOA catheter in a occlusion of the aorta (REBOA). Endovascular balloon oc-
model, using a comprehensive theoretical and practical train- clusion of the aorta is a rapidly emerging technique that uses
ing program. Methods: Six QRT-FF participated in the train- a compliant balloon advanced into the aorta which is then
ing. SOF medics from a previous training served as the control inflated, thereby obstructing flow into the distal circulation
group. A formalized training curriculum included basic anat- above the region of primary hemorrhage as a temporary bleed-
omy and endovascular materials for percutaneous access and ing control measure. REBOA technology has already been suc-
REBOA placement. Key skills included (1) preparation of cessfully used in hospital settings, combat environments, and
an endovascular toolkit, (2) achieving vascular access in the even the earliest phases of prehospital care. 2 3
model, and (3) placement and positioning of REBOA. Results:
QRT-FF had significantly better scores compared with med- Background
ics using endovascular materials (P = .003) and performing In mass casualty situations or in terrorist attacks, medical
the procedure without unnecessary attempts (P = .032). Basic support is typically limited in the immediate vicinity of the
surgical anatomy scores for QRT-FF were significantly better incident. Zones of care are used in the prehospital setting to
than SOF medics (P = .048). QRT-FF subjects demonstrated define locations that are accompanied with different levels of
a significantly higher overall technical skills point score than (personal) safety and require different levels of care. These
medics (P = .030). QRT-FF had a median total time from start zones help delineate the personnel and equipment that can
of the procedure to REBOA inflation of 3:23 minutes, and and should be used depending on the type of incident. The
medics, 5:05 minutes. All six QRT-FF subjects improved their area of the incident can be divided into hot, warm and cold
procedure times–as did four of the five medics. Conclusions: zones, based on medical care in combat situations. In the
Our training program using a task training model can be uti- 2015 Paris Bataclan attacks, not all damage control resusci-
lized for percutaneous femoral access and REBOA placement tation tools were used because of a mismatch in the number
training of QRT-FF without prior ultrasound or endovascu- of casualties and the availability of resources (Box 1). 4,5 In
lar experience. Training the use of advanced bleeding control the past years, several gap analyses have been published on
options such as REBOA, as a secondary occupational task, preventable deaths in both military and civilian settings using
has the potential to improve outcomes for severely bleeding advanced bleeding control options such as REBOA. 6–10 These
casualties in the field. studies conclude that in the military setting, high percentages
of casualties are secondary to NCTH, and smaller groups of
Keywords: vascular access; training; aortic balloon occlu- severely injured that are theoretically amenable to REBOA
sion; firefighters; first responders can be identified in civilian casualty settings. In these situa-
tions, the use of advanced bleeding control options, such as
REBOA, could have saved lives. Professional first responders
in the Netherlands are not commonly trained or equipped in
Introduction
the use of advanced bleeding control options such as REBOA.
Controlling noncompressible truncal hemorrhage (NCTH) Quick Response Team Fire Fighters (QRT-FF) are part of the
is the major lifesaving skill in trauma and vascular surgery. Fire Brigade of the greater The Hague area, the Netherlands.
In NCTH cases, advanced options for truncal and junctional They are an elite group of firefighters with additional medical
*Correspondence to R. Hoencamp, MD, PhD, Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353GA Leiderdorp, the Netherlands
or r.hoencamp@mindef.nl
1 Dr Borger van der Burg is affiliated with the Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands. Dr Vrancken is affiliated
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with the Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands. Capt van Dongen is affiliated with the Department of Surgery,
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Alrijne Hospital, Leiderdorp, the Netherlands; and Defense Healthcare Organization, Mnistry of Defense, Utrecht, the Netherlands. Lt Col
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DuBose is affiliated with the R Adam Cowley Shock Trauma Center, University of Maryland medical System, Baltimore, MD. Col (Ret) Bowyer
is affiliated with the Department of Surgery at Uniformed Services University of the Health Sciences and the Walter Reed National Military med-
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ical Center, Bethesda, MD. Dr Hoencamp is affiliated with the Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands; Defense
Healthcare Organization, Ministry of Defense, Utrecht, the Netherlands; Leiden University Medical Centre, Leiden, the Netherlands; and the
Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands.
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