Page 112 - JSOM Summer 2020

Temporizing Life-Threatening Abdominal-Pelvic Hemorrhage Using
Proprietary Devices, Manual Pressure, or a Single Knee

An Integrative Review of

Proximal External Aortic Compression and Even “Knee BOA”

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Domhnall O’Dochartaigh, MSc, RN ; Christopher Picard, BScN, RN ;
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Peter G. Brindley, MD ; Matthew J. Douma, MN, RN *

ABSTRACT
Introduction: Abdominal-pelvic hemorrhage (i.e., originates lower abdomen, pelvic, and junctional hemorrhage. Less
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below the diaphragm and above the inguinal ligaments) is a optimistically, it remains the leading cause of potentially
major cause of death. It has diverse etiology but is typically survivable death in modern conflict zones and one of the
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associated with gunshot or stab wounds, high force or velocity leading causes of civilian traumatic exsanguination. Indeed,
blunt trauma, aortic rupture, and peripartum bleeds. Because a 2018 retrospective review of mass casualty civilian deaths
there are few immediately deployable, temporizing measures, after gunshot wounds (GSWs) suggested major nonextremity
and the standard approaches such as direct pressure, hemo- blood vessel trauma could be universally fatal. Regardless,
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statics, and tourniquets are less reliable than they are with preoperative interventions include hemostatic gauze pack-
compressible extremity injuries, risk for death resulting from ing ; abdominal aortic and junctional tourniquets 2,7,8 ; combat
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abdominal-pelvic hemorrhage is high. This review concerns clamps ; resuscitative endovascular balloon occlusion of the
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the exciting potential of proximal external aortic compression aorta (REBOA) ; intracavity self-expanding foam; minimally
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(PEAC) as a temporizing technique for life-threatening lower invasive preperitoneal balloon tamponade ; and compressed
abdominal-pelvic hemorrhage. PEAC can be accomplished by hemostatic sponges. 12
means of a device, two locked arms (manual), or a single knee
(genicular) to press over the midline supra-umbilical abdo- Although promising and innovative, these devices have lim-
men. The goal is to compress the descending aorta and slow or itations, including cost, limited kit space, the possibility of
halt downstream hemorrhage while not delaying more defini- malfunction, and the need for rescuers to be initially trained
tive measures such as hemostatic packing, tourniquets, endo- and then to maintain skills. Furthermore, these proprietary
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vascular balloons, and ultimately operative repair. Methods: devices may not be available to the majority of prehospital
Clinical review of the Ovid MEDLINE, In-Process, & Other responders or in environments where hemorrhage occurs (e.g.,
Non-Indexed, and Google Scholar databases was performed work sites, highways, battlefields). These devices also take
for the period ranging from 1946 to 3 May 2019 for studies time to apply, whereas exsanguination can occur in seconds.
that included the following search terms: [proximal] external Accordingly, our review focuses on a maneuver that is simple,
aortic compression OR vena cava compression AND (abdo- cost-free, easy to teach, easy to retain, and requires no addi-
men or pelvis) OR (hemorrhage) OR (emergency or trauma). tional equipment. The goal is the same as with proprietary
In addition, references from included studies were assessed. devices, namely to indirectly prevent downstream hemorrhage
Conclusion: Sixteen studies met the inclusion criteria. Evi- by occluding, via tamponade, the aorta, and thereby gain ad-
dence was grouped and summarized from the specialties of ditional time. Instead of applying a device, rescuers compress
trauma, aortic surgery, and obstetrics to help prehospital re- the aorta, with two locked arms (manual) or one knee (genic-
sponders and guide much-needed additional research, with the ular) atop the supra-umbilical abdomen. This technique has
goal of decreasing the high risk for death after life-threatening been called proximal external aortic compression (PEAC). It
abdominal-pelvic hemorrhage. has since gained two memorable aliases from prehospital per-
sonnel: “ghetto-reboa” and “knee-boa.”
Keywords: hemorrhage; trauma; shock; junctional trauma;
noncompressible hemorrhage; prehospital care; austere PEAC Description
environment; proximal external aortic compression; PEAC
After life-threatening hemorrhagic trauma, rescuers typically
immediately will apply direct pressure to the wound. This is a
life-sustaining first step and precedes more definitive tempori-
Introduction
zation methods, such as hemostatic-gauze packing or tourni-
Optimistically, there is a growing interest in the prehospital quet placement. This is often successful in extremity trauma
and preoperative management of penetrating life-threatening because those body parts are easily compressible, and the
*Correspondence to Royal Alexandra Hospital Emergency Department, 10240 Kingsway Avenue NW, Edmonton, Alberta, Canada T5H3V9;
or matthewjdouma@gmail.com
1 Mr O’Dochartaigh is a clinical nurse specialist, Edmonton Zone Emergency Departments, Alberta Health Services; and Air Medical Crew, Shock
Trauma Air Rescue Society, Edmonton, Alberta, Canada. Mr Picard is a clinical nurse educator, Misericordia Hospital, Edmonton, Alberta,
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Canada. Dr Brindley is a professor, Critical Care Medicine, adjunct professor of anesthesiology and medical ethics, and attending physician,
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Intensive Care Medicine, University of Alberta, Edmonton, Alberta, Canada. Mr Douma is a clinical nurse educator, Royal Alexandra Hospital,
and adjunct associate professor, Critical Care Medicine, University of Alberta.
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