Page 110 - 2022 Spring JSOM

Telemedicine Supervision of

Resuscitative Endovascular Balloon Occlusion of the
Aorta (REBOA) Catheter Placement

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Zaffer Qasim, MBBS ; Christopher Graham, MD *

ABSTRACT
The rapid control of traumatic or nontraumatic exsanguina- Committee on Tactical Combat Casualty Care at or near the
ting hemorrhage in critically injured patients is key to limit- point of injury as a means to address potentially preventable
ing morbidity and mortality in civilian and military practice. military mortality from NCTH. 6
Resuscitative endovascular balloon occlusion of the aorta
( REBOA) has been developed to address potentially pre- However, REBOA is a high-acuity but low-occurrence (HALO)
ventable death from torso or lower extremity junctional procedure requiring specific training to learn the key proce-
hemorrhage. This time-critical, high-acuity, low-occurrence dural aspects of the procedure, which include vascular access
procedure sometimes precludes the appropriate supervision of into the common femoral artery to place an introducer sheath,
clinicians familiar with it. We describe the case of a patient measurement of the catheter to identify the appropriate zone
who had recently undergone liver transplantation presenting of placement, insertion of the compliant balloon catheter itself,
to the intensive care unit (ICU) and found to be in severe non- inflation of the balloon to defined amounts to achieve aortic
traumatic hemorrhagic shock, necessitating REBOA place- occlusion, confirmation (if the situation allows) of the position
ment as part of the resuscitation. The bedside proceduralist using radiography, and finally, careful deflation once surgical
was trained but inexperienced in the procedure and was super- hemorrhage control is achieved. These skills can deteriorate
vised by a telemedicine intensivist, resulting in rapid and safe if a significant period elapses from the clinician’s attending a
insertion. We describe what to our knowledge is the first use course to performing the procedure. Supervision from a more
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of telemedicine to supervise the successful placement of a RE- experienced clinician can be valuable. However, because of the
BOA catheter in a critically ill patient and discuss how this can time-critical nature of managing exsanguinating hemorrhage,
potentially benefit military clinicians working in low-resource, there is limited opportunity for supervision and/or assistance
far-forward environments. when the need for REBOA arises, either in the hospital or in
more austere environments. We describe a situation in which
Keywords: case report; resuscitative endovascular balloon oc- telemedicine supervision was able to successfully address this
clusion of the aorta; REBOA; hemorrhage challenge.

Case Report
Introduction
A 46-year-old man with a history of ulcerative colitis and
Traumatic or nontraumatic noncompressible torso hemor- primary sclerosing cholangitis presented to the emergency de-
rhage (NCTH) is a notable contributor to early and poten- partment (ED) on postoperative day 20 following a liver trans-
tially preventable mortality from hemorrhage in both military plant. His initial procedure was largely uncomplicated except
and civilian practice. This includes bleeding in body cavities for a postoperative hematoma in the surgical field, requiring
1–3
such as the abdomen, pelvis, and retroperitoneum, as well as return to the OR for a washout. He had been discharged and
groin junctional sites. Various attempts have been made to ad- seen in clinic on postoperative day 19 without complaint. His
dress early management of this bleeding, including the use of complaints in the ED included upper abdominal pain, which
REBOA. 4 had increased in severity through the day, nausea, and new
bloody output from his surgical drain. The onset of abdom-
REBOA allows for temporary inflow control of critical hem- inal pain was spontaneous, and he had no recent injury. He
orrhage to facilitate transfer to definitive care, usually in the did report some radiation of the pain to the right scapular tip.
operating room (OR). Data from the Aortic Occlusion for Re-
suscitation in Trauma and Acute Care Surgery registry show it In the ED, he was hypotensive, with vital signs of a heart rate
to be a valid alternative to resuscitative thoracotomy and aor- at 121 beats per minute (bpm), blood pressure of 94/62mmHg,
tic cross-clamping for NCTH management. Zone 1 REBOA and a respiratory rate of 24 breaths per minute. His femoral
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(in which the balloon is placed in the descending thoracic pulses were present equally, but radial pulses were weak bi-
aorta to temporize subdiaphragmatic hemorrhage), along with laterally. He was mildly diaphoretic, and he had tenderness
the use of whole blood, has also been recommended by the without guarding to his upper abdomen. His surgical scar was

*Correspondence to zaffer.qasim@pennmedicine.upenn.edu
1 Dr Zaffer Qasim is affiliated with the Department Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia,
PA. Dr Christopher Graham is affiliated with the Division of Traumatology and Surgical Critical Care, University of Pennsylvania Perelman
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School of Medicine, Philadelphia.
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