Trauma Drama: What is the evidence behind ED REBOA use?

It’s 2 AM and you’re about to walk out to get some coffee when the notification phone rings. The prehospital dispatcher informs you, “24-year-old male with two gunshot wounds to the abdomen, BP 70/P, HR 128, R 30, ETA 5 minutes.” You let the nurses know and call a Trauma Code.

As the patient is wheeled in, your team gets to work. As your intern checks the airway, the patient becomes unresponsive. The nurse tells you that he can’t feel a pulse. You look at the monitor and see sinus tachycardia – the patient is in PEA arrest. Your intern jumps to get the thoracotomy tray, but you stop her and tell her to grab a REBOA. “A what?” she says.

What is REBOA?

REBOA stands for Resuscitative Endovascular Balloon Occlusion of the Aorta. It was first described in the 1950s when it was used by the US military in three patients. Since then, REBOA has been used in various situations including AAA surgery, GI bleeding, and postpartum hemorrhage.^[1] Recently, there has been increased interest in using REBOA in trauma to help control non-compressible hemorrhage. Outside the United States, REBOA has been adopted widely throughout Japan for use in trauma, and London’s Air Ambulance used it in the prehospital setting to save a 24-year-old cyclist who was run over by a skip lorry.^[2] 

What are the indications for REBOA?

Guidelines and Algorithms¹ for REBOA in trauma define indications for placement in either Zone 1 or 3. Variations can be seen in REBOA algorithms from the University of Maryland Shock Trauma, the Joint Theater Trauma System, Western Trauma Association, and Denver Health Medical Center. Specific guidelines are best developed by individual facilities based on the resources available during trauma resuscitations. In general, REBOA is used for hemorrhagic shock secondary to pelvic, abdominal, torso, or truncal hemorrhage. It is contraindicated in patients with blunt aortic or cardiac injuries and patients with penetrating chest or neck trauma.¹

Inaba K. ALGORITHM 2 – REBOA. Western Trauma Association 47th Annual Meeting. 2017.

What evidence exists regarding REBOA in trauma?

REBOA is still in the early phases of use in the US. A recent systematic review^[3] showed that REBOA was effective at elevating SBP in hemorrhagic shock by a mean value of 53 mmHg. Another recent study^[4] conducted at two major Level 1 Trauma Centers compared REBOA to resuscitative thoracotomy and showed that patients with non-compressible truncal hemorrhage without neck or chest trauma who underwent REBOA had fewer early deaths and improved survival. REBOA patients were less likely to die in the ED and were able to make it to the OR or ICU. REBOA is less invasive than thoracotomy with cross-clamping of the aorta and may provide similar results.² Additionally, it can be used in patients presenting with hemorrhagic shock, while thoracotomy is reserved for the pulseless patient. Future prospective studies are needed to better define the survival benefit of REBOA in non-compressible truncal hemorrhage.

How do you place a REBOA?

J Trauma. 2011 Dec; 71(6):1869-72

REBOA in the US was previously a procedure that required placement of a large catheter via cutdown, fluoroscopic confirmation of placement, and vascular repair by the surgical team upon catheter removal. Recent approval and availability of a smaller catheter has made REBOA insertion and removal technically easier to perform and potentially accessible for use by clinicians other than surgeons. In addition, new protocols^[5] allow for the use of ultrasonography to guide access and confirm placement of the catheter by either visualizing the tip in Zone 3 or ensuring it passes above the diaphragm into Zone 1.

Steps for placing the ER REBOA Catheter:^[6]

1. Place a 7Fr arterial line in the common femoral artery (not superficial femoral).
2. Attach 30mL syringe with saline (or mixture of radiocontrast and saline) to balloon port and test the balloon. Then deflate completely and close the stopcock.
3. Measure externally the length you will advance the catheter. For Zone 1 – proximal balloon at xiphoid process. For Zone 3 – proximal balloon slightly above the umbilicus.
4. Place the sheath over the REBOA Catheter to straighten the tip, and flush the arterial line.
5. Use the sheath to introduce the catheter into the access site, pull the sheath back, and advance the catheter to the predetermined length.
6. Open the stopcock and inflate the balloon while observing the arterial tracing and ensuring appropriate pressure response. Do not inject more than 24 mL of fluid.
7. Close the stopcock, secure the catheter in place, and plan for definitive management.
8. Exhale

The balloon’s position can be confirmed using x-ray or ultrasound. If TEE is readily available it can assist in confirming Zone 1 placement as abdominal and thoracic ultrasound may not provide adequate visualization in this zone. Additionally, monitoring the pulse at the left radial artery can ensure the balloon is not advanced too far causing occlusion of the left subclavian artery.⁵ Complications from this procedure include pseudoaneurysm, arterial embolism, and limb ischemia.¹

While advances in REBOA catheters and equipment have potentially made REBOA a tool for EM physicians during trauma resuscitations, education regarding indications for REBOA and formal procedural training should be sought prior to REBOA use. The procedure has been typically performed by surgeons or interventional radiologists in the OR or IR suite. Moving the procedure to the ED requires education of ED staff, repeated simulation of the procedure to ensure timely and effective placement, ability to recognize potential complications, availability of surgical staff to repair complications, and development of institutional and specialty guidelines on its use. Additionally, it is important to realize that REBOA is a temporizing measure and definitive treatment in the OR or IR suite will be necessary. Since balloon occlusion time will be limited, REBOA should only be performed by EM physicians when surgical back-up is immediately available. Hopefully, as more trauma centers develop REBOA capability, we will see additional high-quality data that can guide our future use of this novel tool.

^[1] Napolitano LM. Resuscitative Endovascular Balloon Occlusion of the Aorta. Critical Care Clinics 2017;33(1):55–70.

^[2] Stein DM. REBOA: Who, What and Why? [Internet]. DAS SMACC. 2015 [cited 2017 May 29];Available from: https://www.smacc.net.au/2015/10/reboa-who-what-and-why-deborah-stein/

^[3] 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):324–34.

^[4] Moore LJ, Brenner M, Kozar RA, et al. 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):523–30.

^[5] Ogura T, Lefor AK, Nakamura M, Fujizuka K, Shiroto K, Nakano M. Ultrasound -Guided Resuscitative Endovascular Occlusion of the Aorta in the Resuscitation Area. The Journal of Emergency Medicine 2017;52(5):715–22.

^[6] Weingart S. Podcast 170 – the ER REBOA Catheter with Joe DuBose [Internet]. EMCrit. 2017 [cited 2017 May 29];Available from: https://emcrit.org/podcasts/er-reboa/

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