Emergency department initiated resuscitative endovascular balloon occlusion of the aorta (REBOA) for out‐of‐hospital cardiac arrest is feasible and associated with improvements in end‐tidal carbon dioxide

Abstract

Objectives Out‐of‐hospital cardiac arrest (OHCA) claims the lives of approximately 350,000 people in the United States each year. Resuscitative endovascular balloon occlusion of the aorta (REBOA) when used as an adjunct to advanced cardiac life support may improve cardio‐cerebral perfusion. Our primary research objective was to determine the feasibility of emergency department (ED)‐initiated REBOA for OHCA patients in an academic urban ED. Methods This was a single‐center, single‐arm, early feasibility trial that used REBOA as an adjunct to advanced cardiac life support (ACLS) in OHCA. Subjects under 80 years with witnessed OHCA and who received cardiopulmonary rescuitation (CPR) within 6 minutes were eligible. Results Five patients were enrolled between February 2020 and April 2021. The procedure was successful in all patients and 4 of 5 (80%) patients had transient return of spontaneous circulation (ROSC) after aortic occlusion. Unfortunately, all patients re‐arrested soon after intra‐aortic balloon deflation and none survived to hospital admission. At 30 seconds post‐aortic occlusion, investigators noted a statistically significant increase in end tidal carbon dioxide of 26% (95% confidence interval, 10%, 44%). Conclusion Initiating REBOA for OHCA patients in an academic urban ED setting is feasible. Aortic occlusion during chest compressions is temporally associated with improvements in end tidal carbon dioxide 30 seconds after aortic occlusion. Four of 5 patients achieved ROSC after aortic occlusion; however, deflation of the intra‐aortic balloon quickly led to re‐arrest and death in all patients. Future research should focus on the utilization of partial‐REBOA to prevent re‐arrest after ROSC, as well as the optimal way to incorporate this technique with other endovascular reperfusion strategies.

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

“…Hilbert-Carius et al 24 showed that observed mortality in 26 traumatic OHCA patients receiving REBOA early after hospital admission was 20% significantly lower than predicted by the Revised Injury Severity Score II. Three groups observed a significant increase in end-tidal CO 2 after prehospital or ER REBOA for OHCA, suggesting improved organ circulation 10,14,41,42 . A study by Cralley et al suggested that zone 1 REBOA results in similar or better survival compared with resuscitative thoracotomy, including in patients with penetrating chest injuries, traditionally considered a contraindication for REBOA.…”

“…Three groups observed a significant increase in end-tidal CO 2 after prehospital or ER REBOA for OHCA, suggesting improved organ circulation. 10,14,41,42 A study by Cralley et al suggested that zone 1 REBOA results in similar or better survival compared with resuscitative thoracotomy, including in patients with penetrating chest injuries, traditionally considered a contraindication for REBOA. The ongoing REBOARREST randomized clinical trial will likely provide more insights on REBOA use as ACLS adjunct for OHCA.…”

Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy are associated with similar outcomes in traumatic cardiac arrest

“…Some observational studies report the use of REBOA in the ED for nontraumatic out of hospital cardiac arrest. 16 The REBOARREST trial is an upcoming randomized trial which will hopefully further delineate the role of REBOA in this scenario. 17 Despite the potential advantages of REBOA, there are several important disadvantages.…”

“…Although these potential benefits appear promising, current evidence supporting REBOA in nontraumatic cardiac arrest remains limited. Some observational studies report the use of REBOA in the ED for nontraumatic out of hospital cardiac arrest 16 . The REBOARREST trial is an upcoming randomized trial which will hopefully further delineate the role of REBOA in this scenario 17 …”

Resuscitative endovascular balloon occlusion of the aorta in out-of-hospital cardiac arrest – A Delphi consensus study for uniform data collection

“… 16 , 17 The feasibility of REBOA during CPR in traumatic and non-traumatic cardiac arrest is demonstrated in observational studies, with balloon deployment either in the emergency department or pre-hospital setting. 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 Currently, randomized controlled trials assess the efficacy of REBOA as an adjunct treatment in traumatic hemorrhage 27 and in non-traumatic out-of-hospital cardiac arrest (OHCA). 28 …”