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Novel use of REBOA- A Patient Report

Aorta scheme

 

I recently came across a case file for a novel use of (Resuscitative Endovascular Balloon Occlusion of the Aorta) REBOA in the setting of traumatic cardiac arrest. Typically, REBOA is used for injuries in the pelvis and abdomen. This procedure was born on the battlefield as physicians were looking for a way to get our severely wounded soldiers from the field to definitive care…whether it was a field hospital or a longer air transport out of country. The concept of REBOA is actually not new…it was described in journals more than 50 years ago.

REBOA involves inserting catheter into the common femoral artery and as the name implies, inflating a balloon to occlude aorta, therefore, stopping the bleeding. There are 3 zones that can be occluded in REBOA. Zone I is the descending thoracic aorta between the origin of the left subclavian and celiac arteries. Zone II represents the paravis- ceral aorta between the celiac and the lowest renal artery and zone III the infrarenal abdominal aorta between the lowest renal artery and the aortic bifurcation.(1)

REBOA catheters, depending on the Zone used can be in for only a matter of minutes for Zone 1 and up to 3-6 hours for Zone 3.

REBOA Zones

 

ER REBOA Catheter 1 Pic 3 25 2016 e1502474172212

REBOA Catheter

 

 

In the case of the traumatic arrest from Ohio, they performed a Zone 1 occlusion. Dr. Spalding was quoted below.

While the chief resident placed a resuscitation line in the subclavian vein, Dr. Spalding began inserting an arterial catheter in the patient’s common femoral artery. “Just as I was placing the A-line, the patient lost his pulse and went into cardiac arrest right in front of us.” Dr. Spalding immediately up-sized the introducer sheath, prepared the ER-REBOA™ balloon and inserted the catheter. Simultaneously, the chief resident started blood transfusions while other team members performed external compressions.  “I got the balloon up into Zone 1 and inflated it — and then his heart restarted,” Dr. Spalding said. “The patient regained pulses instantaneously, and pretty soon his blood pressure was 160 systolic.”

While the patient was not in arrest before the decision was made to perform REBOA, it clearly had a positive effect on the patient’s hemodynamics. They had performed a Zone 1 occlusion of about 4 minutes. Enough time to stop the life-threatening hemorrhage and get him to surgery.

He was discharged alive and well 2 days later. A truly amazing story and a nod to this ED team for having protocols in place for implementing REBOA. Even if the balloon never gets inflated, they insert a REBOA catheter as part of the resuscitative effort. I love this!

“Part of our protocol for patients in hemorrhagic shock is to place a right femoral arterial line at the same time we are getting IV access,” Dr. Spalding said. This protocol facilitated an endovascular approach for the arresting patient. “We had the A-line in right away, so when the patient started to rapidly decompensate in front of us, our team was already active and ready to go with REBOA.”

Look around and talk to your trauma centers. Are they looking into REBOA? Have you taken care of a patient they received this life saving procedure? Let us know!

 

References

http://trauma-news.com/2017/08/field-report-ohio-team-uses-reboa-reverse-traumatic-arrest-hemorrhagic-shock/

https://upload.wikimedia.org/wikipedia/commons/9/91/Aorta_scheme.jpg

manufacturer for the REBOA system. http://prytimemedical.com

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