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with pelvic or junctional trauma, we suggest REBOA infla- Conclusion
tion in zone 3, only if the focused abdominal sonography for
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trauma (FAST) is negative. Pelvic trauma is commonly com- Here we proposed the first protocol for REBOA use in a med-
bined with an abdominal trauma, and it is difficult to exclude icalized prehospital system. This protocol is intended to guide
abdominal trauma in the context of pelvic trauma. Therefore, the use of REBOA when needed and to avoid the use of REBOA
the FAST can be used as a diagnostic aid. In the setting of pel- when it is not needed, in order to prevent serious complications
vic trauma with an intraperitoneal effusion noticeable on the or delaying patient care at a trauma center for a patient who
FAST, there is likely an associated abdominal trauma, and the would have arrived there alive without REBOA. Briefly, a phy-
REBOA must be inflated in zone 1. sician must continuously evaluate the risk-benefit balance. We
consider prehospital REBOA exclusively as a life-saving tech-
nique that should be reserved only for patients who would not
Occlusion Strategy
For REBOA inflation in zone 1, we suggest full inflation for otherwise arrive at the hospital alive. That is why this prehospi-
10–20 minutes, followed by gradual deflation, depending on tal protocol differs from existing hospital protocols. The prehos-
the patient’s blood pressure and clinical safety. The total full pital medicalized resuscitation of a patient in hemorrhagic shock
occlusion time must not exceed 30 minutes. This strategy, is based on two principles: proper filling (using blood products
called “partial occlusion” in the literature, appears to reduce or intravenous fluids) and the administration of pressor amines.
the effects of distal ischemia without deteriorating the hemo-
dynamics. 24–28 On the other hand, in zone 3, the REBOA can The French prehospital health system does not include sur-
be fully inflated with a time limit of 2 hours. geons and does not practice resuscitative thoracotomy; there-
fore, REBOA is the only method of aortic clamping. For a
patient who does not respond to filling and pressor amines,
Set-up for an Early Arterial Sheath
For a patient in hemorrhagic shock, the set-up for a femoral and who exhibits continued hemodynamic deterioration, it
introducer can be considered without REBOA placement. We seems necessary to define a maximum dose of noradrenaline
do not suggest a specific noradrenaline dose at which to set beyond which REBOA must be used. Here we have determined
up a femoral introducer because we did not obtain a consen- this threshold to be 0.6µg/kg/min noradrenaline.
sus during the three rounds of our study. However, since early
vascular access is associated with patient survival, it may be Our present study suffers from a low level of evidence, and
beneficial to set up an arterial sheath quickly, according to the thus it will be necessary to adjust this protocol based on clini-
doctor’s judgment. 29 cal data that will be collected in clinical practice, such as hos-
pital mortality within hours of a traumatic injury.
Number of Attempts Author Contributions
REBOA placement is reportedly successful in at least 60% of OT is the main author; he coordinated the co-authors and
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cases. Therefore, we propose to limit the number of arterial was part of the group of experts who corrected the questions
punctures in situ to two attempts or 5 minutes. Should those during the different rounds of review. RJ and DJ were part of
attempts fail, we suggest transport to the hospital without the group of experts who corrected the questions during the
REBOA. The practitioner can then try again to place a REBOA different rounds; they were part of “REBOA task force” of
during transport if it does not delay patient care.
the Paris Fire Brigade. SB, CD, RK, and ST helped draft and
revise the article, providing their expertise as field emergency
Coordination physicians. TH reviewed and gave input on the final version of
We suggest that REBOA placement be performed in coordina- the proposed protocol. BP revised the article and gave input on
tion with the dispatching doctor (i.e., the physician who coor- the final version of the proposed protocol.
dinates ambulances from the call center), and, when possible,
to give advance notice to the trauma center.
Disclosures
The authors have no conflict of interests to disclose.
Aseptic Conditions
We suggest placing the REBOA with minimum aseptic tech- Funding
nique—that is, only sterile gloves and quick skin disinfection— No funding was received for this work.
to waste no time in a case where fast transport to the hospital
remains a priority. References
1. Biffl WL, Fox CJ, Moore EE. The role of REBOA in the control
Limitations of the Delphi Method of exsanguinating torso hemorrhage. J Trauma Acute Care Surg.
As there are no available data regarding REBOA use in a med- 2015;78:1054–1058. doi:10.1097/TA.0000000000000609
icalized prehospital system, we chose to use the Delphi method 2. Johnson NL, Wade CE, Fox EE, et al. Determination of optimal
to inform this practice. Although this method provides only a deployment strategy for REBOA in patients with non-compressible
low level of evidence, it enabled the interrogation of experts in hemorrhage below the diaphragm. Trauma Surg Acute Care Open.
2021;6(1)e000660. doi:10.1136/tsaco-2020-000660
this field and establishment of the foundations for prehospital 3. Ordoñez CA, Rodríguez F, Parra M, et al. Resuscitative endovas-
REBOA use. Borger van der Burg et al. also used this method cular balloon of the aorta is feasible in penetrating chest trauma
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to choose various questions related to REBOA use. Based with major hemorrhage: Proposal of a new institutional deploy-
on the results of our present study and data from the exist- ment algorithm. J Trauma Acute Care Surg. 2020;89(2):311–319.
ing REBOA literature, we have proposed the first protocol for doi:10.1097/TA.0000000000002773
REBOA use in a medicalized prehospital system. This protocol 4. Thabouillot O, Bertho K, Rozenberg E, et al. How many patients
could benefit from REBOA in prehospital care? A retrospective
can be considerably improved upon and must be reviewed and study of patients rescued by the doctors of the Paris fire bri-
edited upon analysis of the first data from its use in real-life gade. J R Army Med Corps. 2018;164(4):267–270. doi:10.1136/
situations. jramc-2018-000915

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