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types of fluid used (blood vs crystalloids), and resuscitation increasingly compact and mobile ultrasound devices with suf-
targets. In addition, there is limited evidence to support a ficient image quality to guide vascular access have been devel-
safe time limit on this intervention. The theoretical downside oped, the authors consider ultrasound an indispensable tool
to prolonged permissive hypotension is decreased end organ for placing any large-bore vascular access and a requirement
perfusion and its sequelae. This is exemplified in a report of for arterial access for REBOA. This view is supported by a
casualties from World War II with extremity injuries and 6 to joint statement from the American College of Surgeons Com-
7 hours of shock before reaching medical care. Despite ade- mittee on Trauma and the American College of Emergency
quate blood resuscitation, the patients never recovered from Physicians regarding clinical use of REBOA. 27
their prolonged shock. In a pig model of a blast injury, pro-
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longed permissive hypotension (resuscitation to SBP 80mmHg) The patient’s pattern of injury highlights multiple challenges
resulted in death of all animals after 209 minutes. Most pre- for REBOA including the theoretical dangers of prehospital
15
hospital studies are in robust trauma networks with prehospi- placement. While some organizations are advocating for pre-
tal times of 60 minutes or less. 16,17 The Trauma Hemostasis and hospital REBOA placement, caution must be exercised. In this
Oxygenation Research (THOR) Network attempts to account case, ongoing tactical concerns prohibited evacuation for 2
for these many confounding variables in its recommendations hours. It is the authors’ opinion that REBOA should only be
on hypotensive resuscitation. For our patient, ongoing tacti- placed when surgical care is immediately available.
18
cal concerns led to the inability to immediately evacuate the pa-
tient. Two hours and thirty minutes elapsed from time of injury At the FRST, A Zone 3 placement was chosen due to the lack
until arrival at the FRST. Ranger medics targeted a palpable of obvious intra-abdominal hemorrhage, as prolonged use of
radial pulse and transfused a total of 10 units of whole blood REBOA in Zone 1 would prolong hepatic, renal, and intes-
before and during transport to surgical care. tinal ischemia, all of which would likely have worsened an
already massive physiologic insult. Movement of the occlusion
Despite receiving 10 units of prehospital blood, the patient ar- balloon to the most distal site allowed by the patient’s status
rived to a forward surgical team in extremis. Given his mech- and pattern of injury should be a top priority, particularly in
anism of injury with obvious pelvic trauma, a Zone 3 REBOA cases where prolonged or repeated aortic occlusion is needed.
was placed via the left common femoral artery with immediate While the patient did have an extensive pelvic injury, the need
improvement in his hemodynamics. for RLE amputation could not be definitively determined at
the Role 2. The right common femoral artery was also ex-
REBOA was first described during the Korean War but was posed within the zone of injury and had a visible subadven-
largely unutilized in trauma until the last decade. Its use has titial hematoma and visible luminal compromise consistent
been described in current combat operations. 19,20 The lack of with dissection or other blunt injury. As a result, access for
effective prehospital solutions for noncompressible torso hem- REBOA was achieved in the left common femoral artery. In
orrhage has brought this technology back to the forefront of cases where one lower limb is clearly nonviable, the side of the
many discussions on battlefield resuscitation and combat ca- nonviable limb should be accessed as it mitigates the clinical
sualty care. One unsettled issue regarding REBOA is the time consequences of any distal thromboembolic complications.
limit it can be safely used prior to achieving surgical hemo-
stasis. Partial REBOA, endovascular variable aortic control Conclusion
(EVAC), and intermittent REBOA are strategies designed to
mitigate the sequelae of distal ischemia and ischemia/reperfu- This case of a severely injured soldier illustrates several novel
sion injury. 21–24 At the Role 2 facility, we used intermittent RE- and extreme techniques including far forward “buddy transfu-
BOA, where the aortic balloon was deflated and then reinflated sions,” intermittent REBOA, and prolonged permissive hypo-
based on the patient’s hemodynamics, to give us more time to tension. While one must be careful to draw conclusions from
obtain surgical control. The balloon was inflated for no more anecdote, this case demonstrates the feasibility and success of
than 45 minutes at any interval, and the total time of intermit- such strategies, which have limited human data to support
tent use was 110 minutes. Data regarding intermittent REBOA their use.
are limited to animal studies, and while the data are favorable,
concerns have been published regarding the extrapolation of Author Contributions
these translational science studies. In addition, it is possible CL wrote the first draft. All other authors contributed to the
25
that the patient’s subsequent LLE ischemia and amputation are case presentation, discussion, and revisions. All authors ap-
related to or were caused by the multiple REBOA placements proved the final version.
and inflations; this is a described complication. Despite the
26
limited data of this experimental strategy as well as a compli- Disclosure
cation associated with its use, we present a case of intermittent The authors have nothing to disclose.
REBOA, which contributed to the patient’s survival.
References
1. Butler FK, Holcomb JB, Schreiber MA, et al. Fluid resuscitation for
In addition, this case demonstrates multiple challenges for hemorrhagic shock in Tactical Combat Casualty Care. J Spec Oper
the placement of REBOA in austere environments. As the Med. 2014;3(June):13–38.
discussion on far-forward austere REBOA placement evolves, 2. Nessen SC, Eastridge BJ, Cronk D, et al. Fresh whole blood use by
this case exemplifies the need for placement by skilled pro- forward surgical teams in Afghanistan is associated with improved
viders able to recognize possible vascular complications and survival compared to component therapy without platelets. Trans-
fusion. 2013;53(January):107–13.
proficient in percutaneous ultrasound guided access. The use 3. Spinella PC, Perkins JG, Grathwohl KW, et al. Warm fresh whole
of ultrasound guidance for arterial access is proven to mini- blood is independetly associated with improved survival for pa-
mize access site complications and should be considered the tients with combat-related traumatic injuries. J Trauma. 2009;66(4
standard of care for any vascular access. Furthermore, as suppl):S69–S76.

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