Non-compressible torso hemorrhage (NCTH) is a leading cause of potentially survivable death.(1, 2)Stannard et al. described NCTH as vascular disruption in one or more of the following: named torso vessel, solid organ injury with grade 4 or greater with shock (systolic blood pressure <90 mmHg) or immediate operation, thoracic cavity, or pelvic fracture with disruption.(3)These injuries are inherently lethal because pressure cannot be applied to the wound in order to control hemorrhage.
Junctional wounds are also difficult to manage and at times, can be confused as a non-compressible torso injury (NCTI). Examples of junctional wounds are injuries proximal to the inguinal ligament and buttocks, but also includes wounds in the axilla and shoulder, and the base of the neck. These wounds are too proximal for limb tourniquets. However, there are methods to control the hemorrhage. Current methods to control junctional hemorrhage include hemostatic dressings, junctional tourniquet, and pelvic binders. For both NCTH and junctional hemorrhage, treatments include tranexamic acid (TXA) and blood, either component therapy in appropriate ratios or preferably whole blood.
Concerted focus has recently been dedicated to the examination of those patients manifesting junctional hemorrhage and/or NCTH that may have been prevented with more rapid delivery to the definitive operative care. The approach to severely injured patients begins with aggressive damage control resuscitation (DCR). This includes the use of whole blood transfusions and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA).
Utilizing low titer group O whole blood is optimal as it is one product, reduces complications such as coagulopathy, and replaces what the patient is losing.(4)REBOA consists of placing a 7-Fr sheath into the common femoral artery (CFA) then passing a long catheter through to the thoracic aorta and inflating a balloon to stop blood flow (and by extension hemorrhage) below the balloon. This is essentially internal aortic cross-clamping as done in emergency thoracotomy. REBOA is a tool that is being implemented for the prehospital setting to address these injuries and part of the DCR plan.
REBOA was first described by Dr. Carl Hughes in the Korea War. There, he performed the procedure on three casualties.(5)The casualties would eventually die from their wounds, but the procedure was successful for temporizing life. The concept of REBOA in trauma was reintroduced in the 1980s – however this was largely before the endovascular revolution occurred. Equipment and training were disparate. Two studies from the time attempting to outline use, but ultimately demonstrated poor outcomes. Low et al. had 13% survival in 15 trauma patients after REBOA(6)and Gupta et al. had 35% survival in 20 trauma patients after REBOA.(7)
Research from animal studies helped established the feasibility. White and colleagues found REBOA increases central perfusion pressures with less physiologic disturbance than thoracotomy with aortic clamping in a model of hemorrhagic shock.(8)Morrison and colleagues found in their swine study that overall mortality for the REBOA group was 25% versus 100% in the group that had no REBOA. The conclusion was REBOA can temporize exsanguinating hemorrhage and restore life-sustaining perfusion, bridging critical physiology to definitive hemorrhage control.Another Morrison study, a retrospective analysis, found that 20% of the 165 UK casualties could have benefited from REBOA and 89 could have benefited from early REBOA.(10)
Emerging data from the United States-based Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry (AORTA) trial suggests that REBOA outcomes are optimal when employed in hypotensive patients with non-compressible hemorrhage prior to loss of signs of life.(11)DuBose astutely stated “waiting until patient requires CPR, no matter your intervention, patients die.”
One of the significant challenges with REBOA is ischemic injury to vital organs such as the kidneys, bowel, and spinal cord. These complications appear to be temporally related to duration of balloon occlusion – no human study has yet defined the safe balloon inflation time, though animal studies certainly appear to place that limit at the 45-60 minute mark with complete aortic occlusion.
More recent animal studies demonstrate increased potential for more refined techniques of occlusion such as partial-REBOA (p-REBOA) (where the balloon does not completely occlude the aorta, allowing some perfusion to vital organs below the balloon) and/or intermittent-REBOA (i-REBOA) (where the balloon is let down completely for specified time periods, again to allow for perfusion of vital organs).(12)This approach to REBOA may make it feasible to use in austere and far forward environments.
When REBOA was making a comeback, clinicians were using 12-14 Fr sheaths. This required the use of guide wires and dilators before inserting the balloon – a process that took considerable time and skill. The introduction of the ER-REBOA™ (Prytime Medical, Boerne, TX) with a 7-Fr sheath eliminated the requirement for passing wires and decreased some of the steps previously required.(13, 14)About the same time, morphometric data was published that allowed for the passing and inflation of the balloon without confirmatory imaging.(15-17)Fluoroscopy or ultrasound can however still be used (and should when feasible).
Prehospital Use of REBOA
Movement of REBOA to outside the hospital began with London’s Air Ambulance. The first published case of prehospital REBOA was a Zone III placement for a pelvic fracture.(18)Since, the Service d’Aide Medicale Urgente (SAMU) in France and prehospital agencies in Japanhave begun to implement and employ REBOA.(19-21)
Perhaps the greatest benefit of prehospital REBOA would be in combat. The US Air Force special operation surgical team (SOST) is showing that physicians from various specialties can place REBOA following appropriate training.(22)It is important to highlight that these providers are not vascular, trauma or acute care surgeons, but general surgeons and emergency medicine physicians (without additional fellowship training in critical care). These successes clearly contradict the assumption of the recent joint statement by the American College of Surgeons and American College of Emergency physicians that states that only emergency physicians with additional critical-care training should be using REBOA.(23)(24) Other military systems have also developed REBOA for prehospital and austere environments.(25, 26)
Currently, a US military unit has implemented REBOA for prehospital use.(27)The protocol for the use includes:
1stattempt: Ultrasound guided percutaneous vascular access
If not successful after 5 minutes move to open
2ndattempt: Femoral artery cutdown
If not successful after 10 minutes or loss of vital signs move to Failure pathway
The failure pathway: Place Abdominal Aortic Junctional Tourniquet (AAJT) if injury amenable to Zone 3 Occlusion. All efforts should cease if injury not amenable to AAJT placement and continue standard DCR.
In the United States, while REBOA has been used by many inside the hospital for several years, the prehospital programs are just now starting to be implemented. The challenges to US prehospital use include lack of clear data of benefit and the variable skill level of different EMS agencies across the US. In addition, some agencies have considerable distances to travel to get from scene to definitive care – this increases the risk from ischemia. However, as the military and European prehospital agencies have demonstrated, it is feasible and may help reduce death from NCTH.
Training
There are only a few models for REBOA training. The ESTARS program was developed for the military, but has not been offered in a number of years.(28)The American College of Surgeon’s has endorsed Basic Endovascular Skills for Trauma (BEST) course, developed at the R Adams Cowley Shock Trauma Center at the University of Maryland Shock Trauma.(29)The BEST course is available at various locations in the United States. Local training opportunities may be available that are not necessarily listed or open to the public. Studies have demonstrated the BEST course can improve novice and prehospital provider’s skills with REBOA.(27, 30, 31)
The limitations to these courses include a need for some prior experience in acute and/or critical care, little discussion about ultrasound use, and variable fidelity to teach the technique. These courses are specifically designed to train in-hospital clinicians in the technique and may not specifically address the challenges of austere or prehospital implementation.
However, with the right training, prehospital providers can learn to perform REBOA safely and effectively with a sustained working knowledge. Achieving common femoral artery (CFA) access is critical to success.(32)CFA access in the prehospital setting is not a standard skill. Most who work in the prehospital setting have little experience or degraded central access skills. Options vary and can include early access with an 18-guage or 5-French catheter (which can then be upsized to a 7-French sheath over a wire). Although access can be achieved through cutdown, the preferred technique is ultrasound-guided percutaneous access.Ross and Redman demonstrated a mean time for percutaneous placement in field/flight conditions can be as low as 6.3 minutes and an open placement in field/flight conditions at 13.6 minutes.(27)
To be most successful, any REBOA course designed for prehospital implementation requires significant preparatory work. The fundamentals are a must-mastery of these principles and procedures. They are markers that one has sufficient judgement to use REBOA in the right circumstances. The feasibility of an extensive course on ultrasound for the prehospital setting is unlikely in a REBOA course and ideally students need working knowledge prior to coming on the course. Candidates should be prepared to have an implementation plan of aggressive DCR within their system based on principles learnt on the course.
The Resuscitation Adjuncts: Prehospital Transfusion & REBOA (RAPToR) course is 1.5 day course specifically designed for prehospital use of REBOA and whole blood. There is heavy emphasis on a team approach to resuscitation and encourages the medical director attend along with paramedics, flight nurses, and/or advanced practice practitioners. Furthermore, the creators of the RAPToR coursehave developed a prehospital registry, appropriately named, Registry of Application of Prehospital REBOA (RAPTOR).This registry will prospectively collect data from participating systems and also collect any available retrospective data.
While the RAPToR course will allow for a sustained understanding of REBOA, refresher training curriculum must be implemented too. Regular refresher training is an identified shortfall resulting in skill decay. Preshospital teams should strongly consider supplementing attendance at a course like RAPToR with regular refresher training. Additional skill maintenance can be achieved by having prehospital clinicians obtain CFA access with an 18-gauge catheter as part of normal resuscitation for their critically-ill patients.
The authors feel a perfused cadaver is the preferred model for training REBOA. Though relatively simple to create, there may be some limitations to access to cadaver use. However, they can be adapted by an EMS service for relatively low cost outside of a hospital environment.(33)Virtual reality simulators may be an option in the future.
Summary
There is no doubt, concern about the benefits of REBOA, both inside and outside the hospital.(34-36). Overarching concerns include appropriate patient selection and limitation of complications. Specific challenges to prehospital use, especially in the US, include training and equipment costs, skills maintenance and quality assurance, and the challenges of ischemic burden given the distances some prehospital systems have to cover to get to definitive care. What is not in doubt is that there remains a significant burden of potentially preventable prehospital death from NCTH. We need to invest in feasible solutions to limit this – and that may well be moving care forward and applying the principles of DCR in the field with modalities such as whole blood and REBOA.
Andrew Fisher, MPAS, PA-C, LP
Third year medical student at Texas A&M College of Medicine in Temple, TX. He is also a physician assistant in the Texas National Guard and previous senior physician assistant assigned to the 75th Ranger Regiment.
Zaffer Qasim, MD
Physician at Perelman School of Medicine at the University of Pennsylvania.
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