Page 39 - JSOM Fall 2024

REBOA Use in a Medicalized Prehospital Setting

Proposal for a First Protocol Based on the Delphi Method

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Oscar Thabouillot, MD *; Romain Jouffroy, MD ;
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Daniel Jost, MD ; Sébastien Beaume, MD ; Clément Derkenne, MD ;
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Romain Kedzierewicz, MD ; Stéphane Travers, MD, PhD ;
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Tal Horer, MD, PhD ; Bertrand Prunet, MD, PhD 9

ABSTRACT
Background: The resuscitative endovascular balloon occlusion Introduction
of the aorta (REBOA) technique controls abdominal, pelvic,
junctional, and postpartum hemorrhage via aortic endocla- The resuscitative endovascular balloon occlusion of the aorta
mping. There are no protocols or clear indications guiding (REBOA) technique enables the temporary control of abdom-
REBOA use in a two-tiered prehospital emergency medical inal, pelvic, and junctional hemorrhage through aortic en-
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system, as found in France. We conducted a Delphi study to doclamping. There are multiple different local intra-hospital
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clarify the indications and contraindications for REBOA ap- protocols for REBOA use.
plication in such a system. Methods: We performed a Delphi
study in three rounds with an international group of doctors In many English-speaking countries, prehospital response
with REBOA expertise and clinical experience (members of the teams depend on paramedics; however, in France, the pre-
EndoVascular and Trauma Management Society). Based on hospital healthcare system mainly relies on medicalization
the consensus answers, complemented by existing data in the upon engagement of the vital prognosis. This means that
literature, we developed a protocol for REBOA use in a medi- the ambulance system in France operates at two levels: for
calized prehospital setting. Results: We identified 10 questions non-life-threatening emergencies, an ambulance composed ex-
that were not answered in the literature and submitted them clusively of first responders is sent; as soon as the situation
to 21 experts. Over three rounds, consensus was reached on becomes life-threatening, an ambulance with a medical team
these 10 questions. The most important ones were “In your is sent to support the rescue team. Intensive care ambulances
opinion, in a hemorrhagic patient, vascularly well-filled and respond in a backup capacity to the first responders—bringing
whose hemodynamics remain unstable with 3mg/h of norepi- an emergency doctor, a nurse, and a driver, along with on-
nephrine, should we inflate a REBOA to prevent the patient’s board equipment equivalent to that available in a resuscitation
death and get them to the operating room alive?” and “In the room. Notably, in France, no surgeon is sent out in the prehos-
case of REBOA placement (zone I) in the prehospital setting, pital setting; therefore, it is not possible to perform surgical
would you agree that the maximum occlusion duration is ap- procedures, such as emergency thoracotomy, to stop bleeding.
proximately 30 minutes, with a partial or intermittent occlu- One previous study of patients who received prehospital care
sion when possible?” Conclusion: We propose a protocol for from the Paris Fire Brigade (BSPP) in 1 year, showed that ap-
REBOA use in a medicalized prehospital setting. This protocol proximately 37 out of 1,159 per year could have benefited
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clarifies that hemorrhagic shock, despite a noradrenaline (also from REBOA. Furthermore, approximately 85% of those pa-
known as norepinephrine) dose of 0.6µg/kg/min, is considered tients died before arriving at the hospital, suggesting that the
too serious for the patient to be transported to the trauma BSPP should have REBOA capability.
center without REBOA. Moreover, it clarifies that a zone 1
REBOA should be inflated for maximum 30 minutes and with While the REBOA technique seems potentially useful for pa- 5
a partial occlusion strategy, if possible. This protocol should tients in settings without any other therapeutic resources,
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be updated based on feedback following the establishment of REBOA may result in serious complications. Therefore, it
prehospital REBOA and large randomized studies. is necessary to accurately identify patients who would not
arrive at the hospital alive without prehospital REBOA. The
literature includes only limited data about prehospital REBOA
Keywords: REBOA; hemmorhagic shock; trauma, protocol;
out-of-hospital; DELPHI survey use, and most publications are from the English and American
medical systems, where prehospital services are less medical-
ized than those in France.
*Correspondence to thabouillot@hotmail.com
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1 Dr. Oscar Thabouillot is an emergency physician in the French Military Health Service, 2nd Medical Center, Versailles, France. Dr. Romain
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Jouffroy is an emergency physician in the Paris Fire Brigade – Emergency Medicine Department, Paris, France. Dr. Daniel Jost is emergency
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physician the Paris Fire Brigade – Emergency Medicine Department, Paris, France. Dr. Sébastien Beaume is an emergency physician in the French
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Military Health Service, 10th Medical Center, Marseille, France. Dr. Clément Derkenne is an emergency physician in the French Military Health
Service, 2nd Medical Center, Versailles, France. Dr. Romain Kedzierewicz is an emergency physician the Paris Fire Brigade – Emergency Medicine
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Department, Paris, France. Dr. Stéphane Travers is an emergency physician in the Paris Fire Brigade – Emergency Medicine Department, Paris,
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France. Dr. Tal Horer is head of the Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Medicine and
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Health, Örebro University, Örebro, Sweden. Dr. Bertrand Prunet is head of the Paris Fire Brigade – Emergency Medicine Department, Paris, France.
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