Samuel A. Tisherman, Megan L. Brenner
Hemorrhage from non-compressible torso (thorax, abdomen, pelvis) injuries is the leading cause of potentially preventable death from trauma, particularly in the military setting. When trauma patients have active hemorrhage, resuscitation is not possible until hemostasis can be obtained. Every minute counts. Although extremity hemorrhage can be controlled by a tourniquet, this is not true for non-compressible torso hemorrhage, which typically requires intervention by a surgeon or interventional radiologist in the hospital. Consequently, there is a great public health need for novel, faster methods of hemorrhage control as close to the site of injury as possible.
For selected patients who have suffered a cardiac arrest or are in extremis from exsanguinating trauma, surgeons may elect to perform an Emergency Department Thoracotomy (EDT), usually with clamping of the distal thoracic aorta. Long-term survival is rare, perhaps due to the delay during transport, severity of the underlying injuries, the physiologic insult already present, or the additional surgical trauma. Although there is limited experience with out-of-hospital thoracotomy in selected patients with cardiac arrest due to stab wounds, this remains a hospital-based procedure performed by surgeons, yet with dismal outcomes.
Until recently, endovascular approaches to hemorrhage control were under the purview of vascular surgeons and interventional radiologists. Vascular surgeons have used an intravascular balloon to decrease hemorrhage from the aorta for many years., Emergency medicine physicians in Japan have been using the technique in the ER (and a few cases in the pre-hospital setting) for over a decade, , , with promising results. More recently in the US, trauma surgeons have successfully used formal training, to develop Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for decreasing hemorrhage from severe abdominal or pelvic injuries., ,
In this issue of Resuscitation, Sadek et al. have described a case report of successful out-of-hospital use of REBOA in a patient suffering massive bleeding from the pelvis following a fall. Perhaps more informative than the details of the specific case is the process by which they developed the protocol. They brought together a multi-disciplinary group so that all key disciplines were involved. They then developed a structured training, education, and oversight plan. The importance of such a thoughtful approach cannot be overemphasized. Placement of REBOA carries significant risks, including arterial injury at the insertion site, potential disruption of an undiagnosed aortic injury as in the case described, ischemic injury to vital organs, and cardiovascular collapse during balloon deflation. The potential for harm, if not placed and managed properly, is enormous. Trauma surgeons have developed educational programs to learn proper patient selection, REBOA placement technique, and REBOA management., Other specialists interested in placing REBOA should similarly undergo dedicated training. Education and coordination of all providers involved in managing patients who undergo REBOA placement are critical for success.
Choosing the most appropriate patients for novel interventions, such as REBOA, is also critical. One must give standard care a chance, while not waiting so long to intervene that no therapy can help. Guidelines for use of REBOA in the hospital have been developed. Applying similar criteria for use of REBOA out of the hospital can be challenging without the diagnostic imaging available in the ED. Use of ultrasound is feasible outside the hospital and can be extremely useful for obtaining vascular access and potentially for positioning of the REBOA catheter.
The history of the out-of-hospital management of critically-ill and injured patients has evolved remarkably over the past 50 years. Although one could argue the merits of a “scoop and run” policy for trauma victims, the fact remains that paramedics and emergency physicians have successfully provide advanced airway management, intravenous medications, resuscitation fluids (including blood products), and cardiopulmonary resuscitation outside the hospital, saving numerous lives. Davies and Lockey have already demonstrated the feasibility of thoracotomies outside the hospital for stab wounds to the chest. They have applied a similarly thoughtful approach to use of REBOA in this setting.
Moving forward, key hurdles for REBOA use by non-surgeons in, or out of, the hospital setting will include patient selection and arterial access. For instance, the increase in afterload produced by placement of REBOA can be catastrophic in the presence of an undiagnosed proximal aortic injury. Regarding access, more than half of the REBOA procedures performed in the US so far required open groin cut down, and most of those patients were in, or near, arrest. Providers need to be weary of taking time and resources away from traditional resuscitative measures in an effort to gain percutaneous access. If percutaneous access is not possible, REBOA cannot be performed unless open groin cut down is in the skill set of the non-surgeon provider.
Sadek et al. should be commended for demonstrating the feasibility of taking advanced resuscitation technologies out of the hospital. They have accomplished this with the rigor that should be a model for resuscitation researchers attempting to introduce novel, invasive therapies, such as REBOA. The payoff in terms of earlier control of hemorrhage may significantly improve outcomes of patients who currently succumb to exsanguinating hemorrhage.
Samuel A. Tisherman: No conflicts of interest to disclose.
Megan Brenner: Clinical advisory board member for Prytime Medical Inc. Principal investigator for a grant from the Department of Defense, entitled, “Clinical Study of Resuscitative Endovascular Balloon Occlusion of the Aorta for Severe Pelvic Fracture & Intra-Abdominal Hemorrhagic Shock using Continuous Vital Sign and Video Monitoring.” Co-investigator for a grant from the Department of Defense, entitled, “Physiologic Response to Prolonged Resuscitative Endovascular Balloon Occlusion of the Thoracic Aorta in Swine.”