A Practical Approach to Introducing Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), the Problems Encountered and Lessons Learned

Abstract

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an endovascular procedure which utilises a catheter based balloon device to achieve aortic occlusion. The aim of this resuscitative measure is to improve blood pressure proximal to the occlusion site and therefore preserve cardiac and cerebral perfusion in order to prevent cardiac arrest; additionally there is a relative reduction in arterial inflow to the site of injury. Endovascular techniques are gaining acceptance for the in-hospital management of haemorrhage, however their use in pre-hospital care is still limited. This is due to a number of factors including the technical challenges, training and skill sets of pre-hospital care teams and the potential for harm of REBOA, particularly with extended balloon occlusion times. However, non compressible torso haemorrhage is associated with a mortality of approximately 50% and a significant proportion of these deaths occur in the pre-hospital phase of care. In the exsanguinating patient, resuscitative thoracotomy (RT) with direct aortic compression is often the only means to control haemorrhage. This resuscitative measure is now an established pre-hospital intervention which has significantly improved outcomes in the context of penetrating trauma, particularly thoracic injury. In the context of blunt injury and subdiaphragmatic haemorrhage, however, the outcomes from pre-hospital resuscitative thoracotomy remain poor. We present our initial technique for successfully introducing REBOA for the pre-hospital management of exsanguinating pelvic or groin heamorrhage following trauma, our indications for REBOA and comment on the problems and limitations encountered as well the lessons learned.

Consensus on resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian (pre-hospital) trauma care: a Delphi study

“…Our algorithm could assist in REBOA candidate selection in addition to using pragmatic clinical signs as the 'hateful eight'. 28 Our panel did not agree that prehospital REBOA could be used as adjunct to ACLS in witnessed (non)traumatic OHCA. However, performing aortic occlusion shortly after onset of cardiac arrest could possibly lead to improved mortality outcomes.…”

“…[12][13][14][15] Implementing prehospital REBOA in resource limited settings requires a structured and coordinated system with clear protocols and skilled teams. Chana et al 28 described the evolving protocol and technique of London's Air Ambulance where the necessary materials were put in separate step-wise packages to simplify the procedure. Resuscitative endovascular balloon occlusion of the aorta competence cannot be mastered by mere real-time cases due to the estimated small number of eligible patients.…”

“…Question remains what the alternative should be in these exsanguinating patients. Our algorithm could assist in REBOA candidate selection in addition to using pragmatic clinical signs as the ‘hateful eight’ 28 …”

Prehospital invasive arterial blood pressure monitoring in critically ill patients attended by a UK Helicopter Emergency Medical Service – a retrospective observational review of practice

“…Critical Care Paramedics (CCP) receive training in peripheral arterial catheterisation and point-of-care-ultrasound (POCUS), including vascular access, and then practice under physician supervision until achieving independent sign-off. Ultrasound-guided femoral arterial cannulation is formally trained as part of the local Specialist Percutaneous Emergency Aortic Resuscitation (SPEAR) programme utilising a Seldinger technique (9,10).…”

Revisiting the promise, practice and progress of resuscitative endovascular balloon occlusion of the aorta

“…There remains a cohort of trauma patients, who were not recruited into the UKRT who die in the prehospital phase of care due to exsanguination and associated myocardial hypoperfusion, or from the effects of hypoperfusion in the first 3-72 h [41][42][43]. Such patients may survive to hospital with prehospital use of REBOA and for this reason services like London's Air Ambulance (LAA) and the Service d'aide m edicale urgente (SAMU) in Paris continue to examine and develop a prehospital REBOA capability [44,45]. Prehospital REBOA is feasible [19,45] and Partial-REBOA [46] has the potential to increase timelines, reduce inflammatory sequelae and improve survival [47].…”