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Open Access 01-12-2018 | Methodology

Three cases of resuscitative endovascular balloon occlusion of the aorta (REBOA) in austere pre-hospital environment—technical and methodological aspects

Authors: J. C. de Schoutheete, I. Fourneau, F. Waroquier, L. De Cupere, M. O’Connor, K. Van Cleynenbreugel, J. C. Ceccaldi, S. Nijs

Published in: World Journal of Emergency Surgery | Issue 1/2018

Abstract

Background

The present paper describes three cases where ER-REBOA® was used with partial aorta occlusion (AO), by performing a partial resuscitative endovascular balloon occlusion of the aorta or pREBOA, in an austere pre-hospital military environment.

In addition, because no specific REBOA algorithm for pre-hospital environment exists yet, this paper seeks to fill this gap, proposing a new pragmatic REBOA algorithm.

Methods

Belgian Special Operations Surgical Team applied REBOA in three patients according to a decisional algorithm, based on the MIST acronym used for trauma patients. Only 3 ml, in the first instance, was inflated in the balloon to get AO. The balloon was then progressively deflated, and reperfusion was tracked through changes of end-tidal carbon dioxide (EtCO₂).

Results

Systolic blood pressure (SBP) before ER-REBOA® placement was not higher than 60 mmHg. However, within the first 5 min after AO, SBP improved in all three cases. Due to the aortic compliance, a self-made pREBOA was progressively achieved while proximal SBP was raising with intravenous fluid infusion. Afterwards, during deflation, a steep inflection point was observed in SBP and EtCO₂.

Conclusions

ER-REBOA® is suitable for use in an austere pre-hospital environment. The MIST acronym can be helpful to select the patients for which it could be beneficial. REBOA can also be performed with pREBOA in a dynamic approach, inflating only 3 mL in the balloon and using the aortic compliance. Furthermore, while proximal SBP can be convenient to follow the occlusion, EtCO₂ can be seen as an easy and interesting marker to follow the reperfusion.

NAEMT. Tactical Combat Casualty Care Guidelines for All Combatants. https://www.naemt.org/docs/default-source/education-documents/tccc/tccc-ac/updates-1708/00-tccc-ac-guidelines-1708/tccc-guidelines-for-all-combatants-1708.pdf?sfvrsn=7559ca92_2. Accessed 5 Aug 2018.

Prytime Medical™. ER-REBOA™. http://prytimemedical.com/product/#er-reboa. Accessed 5 Aug 2018.

Med Device Online. Pryor Medical Devices Receives 510(k) Clearance For Distribution Of ER-REBOA Catheter. https://www.meddeviceonline.com/doc/pryor-medical-devices-receives-k-clearance-for-distribution-of-er-reboa-catheter-0001. Accessed 5 Aug 2018.

Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71(6):1869–72. https://doi.org/10.1097/TA.0b013e31823fe90c.CrossRefPubMed

Irahara T, Sato N, Moroe Y, Fukuda R, Iwai Y, Unemoto K. Retrospective study of the effectiveness of intra-aortic balloon occlusion (IABO) for traumatic haemorrhagic shock. World J Emerg Surg. 2015;10(1):1. https://doi.org/10.1186/1749-7922-10-1.CrossRefPubMedPubMedCentral

Tsurukiri J, Akamine I, Sato T, et al. Resuscitative endovascular balloon occlusion of the aorta for uncontrolled haemorrahgic shock as an adjunct to haemostatic procedures in the acute care setting. Scand J Trauma Resusc Emerg Med. 2016;24(1):13. https://doi.org/10.1186/s13049-016-0205-8.CrossRefPubMedPubMedCentral

Lallemand MS, Moe DM, McClellan JM, Smith JP, Daab L,Marko S, Tran N, Starnes B, Martin MJ. Resuscitative endovascular balloon occlusion of the aorta for major abdominal venous injury in a porcine hemorrhagic shock model. J Trauma Acute Care Surg. 2017;83(2):230–236.CrossRef

Russo RM, Neff LP, Lamb CM, et al. Partial resuscitative endovascular balloon occlusion of the aorta in swine model of hemorrhagic shock. J Am Coll Surg. 2016;223(2):359–68. https://doi.org/10.1016/J.JAMCOLLSURG.2016.04.037.CrossRefPubMed

Teeter WA, Matsumoto J, Idoguchi K, Kon Y, Orita T, Funabiki T, Brenner ML, Matsumura Y. Smaller introducer sheaths for REBOA may be associated with fewer complications. J Trauma Acute Care Surg. 2016;81(6):1039–45.CrossRef

10.

Brenner M, Teeter W, Hoehn M, Al E. Use of resuscitative endovascular balloon occlusion of the aorta for proximal aortic control in patients with severe hemorrhage and arrest. JAMA Surg. 2018;153(2):130–5.CrossRef

11.

Morrison JJ, Galgon RE, Jansen JO, Cannon JW, Rasmussen TE, Eliason JL. A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock. J Trauma Acute Care Surg. 2016;80(2):324.CrossRef

12.

Gamberini E, Coccolini F, Tamagnini B, et al. Resuscitative endovascular balloon occlusion of the aorta in trauma: a systematic review of the literature. World J Emerg Surg. 2017;12(1):42. https://doi.org/10.1186/s13017-017-0153-2.CrossRefPubMedPubMedCentral

13.

Saito N, Matsumoto H, Yagi T, Hara Y, Hayashida K, Motomura T, Mashiko K, Iida H, Yokota H, Wagatsuma Y. Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2015;78(5):897–903.CrossRef

14.

Moore LJ, Brenner M, Kozar RA, Pasley J, Wade CE, Baraniuk MS, Scalea T, Holcomb JB. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg. 2015;79(4):523.CrossRef

15.

Hörer TM, Cajander P, Jans A, Nilsson KF. A case of partial aortic balloon occlusion in an unstable multi-trauma patient. Trauma. 2016;18(2):150–4. https://doi.org/10.1177/1460408615624727.CrossRef

16.

Johnson MA, Neff LP, Williams TK, DuBose JJ; EVAC Study Group. Partial resuscitative balloon occlusion of the aorta (P-REBOA): Clinical technique and rationale. J Trauma Acute Care Surg. 2016;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S133–S137.

17.

Russo RM, Williams TK, Grayson JK, Lamb CM, Cannon JW, Clement NF, Galante JM, Neff LP. Extending the golden hour: Partial resuscitative endovascular balloon occlusion of the aorta in a highly lethal swine liver injury model. J Trauma Acute Care Surg. 2016;80(3):372–8.CrossRef

18.

Matsumura Y, Matsumoto J, Kondo H, Idoguchi K, Ishida T, Kon Y, et al. Fewer REBOA complications with smaller devices and partial occlusion: evidence from a multicentre registry in Japan. Emerg Med J. 2017;34(12):793. https://doi.org/10.1136/emermed-2016-206383.CrossRef

19.

Sadeghi M, Hörer TM, Forsman D, et al. Blood pressure targeting by partial REBOA is possible in severe hemorrhagic shock in pigs and produces less circulatory, metabolic and inflammatory sequelae than total REBOA. Injury. 2018;0(0). doi:https://doi.org/10.1016/j.injury.2018.09.052

20.

Courtney DM, Watts JA, Kline JA. End tidal CO2 is reduced during hypotension and cardiac arrest in a rat model of massive pulmonary embolism. Resuscitation. 2002;53(1):83–91. https://doi.org/10.1016/S0300-9572(01)00504-4.CrossRefPubMed

21.

McGillicuddy DC, Tang A, Cataldo L, Gusev J, Shapiro NI. Evaluation of end-tidal carbon dioxide role in predicting elevated SOFA scores and lactic acidosis. Intern Emerg Med. 2009. https://doi.org/10.1007/s11739-008-0153-z.CrossRef

22.

Stensaeth KH, Sovik E, Haig INY, Skomedal E, Jorgensen A. Fluoroscopy-free resuscitative endovascular balloon occlusion of the aorta (REBOA) for controlling life threatening postpartum hemorrhage. PLoS One. 2017. https://doi.org/10.1371/journal.pone.0174520.CrossRef

23.

Manley JD, Mitchell BJ, DuBose JJ, Rasmussen TE. A modern case series of resuscitative endovascular balloon occlusion of the aorta (REBOA) in an out-of-hospital, combat casualty care setting. J Spec Oper Med. 2017;17(1):1–8.PubMed

24.

Northern DM, Manley JD, Lyon R, et al. Recent advances in austere combat surgery: use of aortic balloon occlusion as well as blood challenges by special operations medical forces in recent combat operations. J Trauma Acute Care Surg. 2018. https://doi.org/10.1097/TA.0000000000001966.

25.

Sadek S, Lockey DJ, Lendrum RA, Perkins Z, Price J, Davies GE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the pre-hospital setting: an additional resuscitation option for uncontrolled catastrophic haemorrhage. Resuscitation. 2016. https://doi.org/10.1016/j.resuscitation.2016.06.029.CrossRef

26.

North Atlantic Treaty Organization. Allied Joint Doctrine for Medical Support. AJP-4.10. https://www.coemed.org/images/Courses_pdf/stanags/mmsop/2228_AJP-4.10%20EDB%20V1%20E.pdf EDB V1 E.pdf. Published 2015. Accessed 5 Aug 2018.

27.

Hodgetts T, Deane S, Gunning K. Trauma rules. London: BMJ Publishing Group; 1997.

28.

Centers for Disease Control and Prevention. Guidelines for field triage of injured patients. https://fems.dc.gov/sites/default/files/dc/sites/fems/publication/attachments/CDC%20Guidelines%20for%20Field%20Triage%20of%20Injured%20Patients.pdf. Published 2012. Accessed 5 Aug 2018.

29.

Linnebur M, Inaba K, Haltmeier T, et al. Emergent non-image-guided resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter placement: a cadaver-based study. J Trauma Acute Care Surg. 2016. https://doi.org/10.1097/TA.0000000000001106.CrossRef

30.

EMCrit RACC. Podcast 170 – the ER REBOA Catheter with Joe DuBose. https://emcrit.org/emcrit/er-reboa/. Accessed 5 Aug 2018.

31.

Gennarelli TA, Wodzin E. AIS 2005: a contemporary injury scale. Injury. 2006. https://doi.org/10.1016/j.injury.2006.07.009.CrossRef

32.

Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma Acute Care Surg. 1974;14(3):187–96.CrossRef

33.

Osler T, Baker SP, Long W. A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma Acute Care Surg. 1997;43(6):922–5.CrossRef

34.

Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma score and the injury severity score. J Trauma. 1987;27(4):370–8.CrossRef

35.

Biffl WL, Fox CJ, Moore EE. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma Acute Care Surg. 2015;78(5):1054–8.CrossRef

36.

DuBose JJ, Scalea TM, Brenner M, Skiada D, Inaba K, Cannon J, Moore L, Holcomb J, Turay D, Arbabi CN, Kirkpatrick A, Xiao J, Skarupa D, Poulin N; AAST AORTA Study Group. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;81(3):409–19.

37.

Romagnoli A, Teeter W, Pasley J, Hu P, Hoehn M, Stein D, Scalea T, Brenner M. Time to aortic occlusion: It’s all about access. J Trauma Acute Care Surg. 2017;83(6):1161–1164.CrossRef

38.

Davidson AJ, Russo RM, Ferencz SE, Cannon JW, Rasmussen TE, Neff LP, Johnson MA, Williams TK. Incremental balloon deflation following complete resuscitative endovascular balloon occlusion of the aorta results in steep inflection of flow and rapid reperfusion in a large animal model of hemorrhagic shock. J Trauma Acute Care Surg. 2017;83(1):139–143.CrossRef

39.

Taylor JRIII, Harvin JA, Martin C, Holcomb JB, Moore LJ. Vascular complications from resuscitative endovascular balloon occlusion of the aorta: Life over limb? J Trauma Acute Care Surg. 2017;83(1 Suppl 1):S120–S123.CrossRef

40.

Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001–2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6).CrossRef

41.

Brenner M, Hoehn M, Pasley J, Dubose J, Stein D, Scalea T. Basic endovascular skills for trauma course: Bridging the gap between endovascular techniques and the acute care surgeon. J Trauma Acute Care Surg. 2014;77(2):286–91.CrossRef

42.

Villamaria CY, Eliason JL, Napolitano LM, Stansfield RB, Spencer JR, Rasmussen TE. Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course: Curriculum development, content validation, and program assessment. J Trauma Acute Care Surg. 2014;76(4):929–35.CrossRef

43.

Endovascular Resuscitation and Trauma Management. EVTM Workshop. https://www.jevtm.com/workshop/. Accessed 5 Aug 2018.

44.

Reva VA, Hörer TM, Makhnovskiy AI, Sokhranov M V, Samokhvalov IM, DuBose JJ. Field and en route resuscitative endovascular occlusion of the aorta: A feasible military reality? J Trauma Acute Care Surg. 2017;83(1 Suppl 1):S170–S176.CrossRef

45.

Napolitano LM. Resuscitative endovascular balloon occlusion of the aorta. Crit Care Clin. 2017;33(1):55–70. https://doi.org/10.1016/j.ccc.2016.08.011.CrossRefPubMed

Title: Three cases of resuscitative endovascular balloon occlusion of the aorta (REBOA) in austere pre-hospital environment—technical and methodological aspects
Authors: J. C. de Schoutheete
I. Fourneau
F. Waroquier
L. De Cupere
M. O’Connor
K. Van Cleynenbreugel
J. C. Ceccaldi
S. Nijs
Publication date: 01-12-2018
Publisher: BioMed Central
Published in: World Journal of Emergency Surgery / Issue 1/2018
Electronic ISSN: 1749-7922
DOI: https://doi.org/10.1186/s13017-018-0213-2

At a glance: The STEP trials

Springer Medicine

Three cases of resuscitative endovascular balloon occlusion of the aorta (REBOA) in austere pre-hospital environment—technical and methodological aspects

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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