key takeaways
- Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique used in trauma patients for non-compressible hemorrhage below the diaphragm.
- Studies of REBOA in pre-hospital trauma cases indicate that it has the potential to help control hemorrhage and prevent cardiac arrest.
- Additional evidence, protocols, and training are needed for use of REBOA to increase in the United States.
All instances of cardiac arrest are high-stakes, life-or-death events, but cases of traumatic cardiac arrest tend to be especially complex. Responders have the added challenge of managing the trauma that precipitated the arrest while also executing a high-quality resuscitation response.
That’s why responders have to stay current on new and emerging trends in trauma resuscitation that have the potential to help their patients — and ideally prevent an arrest from happening at all. Recently, we published an article on the use of tranexamic acid in trauma resuscitation, and how it can help prevent coagulopathy in patients with severe hemorrhage. Today, we’re covering another technique that responders might want to keep on their radar for trauma cases: resuscitative endovascular balloon occlusion of the aorta (REBOA).
Keep reading to find out what REBOA is, how it might help in trauma cases, and what would be needed for its use to expand in the United States.
What is REBOA, and how can it help in trauma cases?
What is REBOA?
REBOA is used for non-compressible hemorrhage below the diaphragm. It’s a minimally invasive alternative to cross-clamping of the hemorrhaging vessel. It involves placement of a percutaneously inserted balloon in the aorta to help quickly control the hemorrhage until more definitive control is possible.1
How can REBOA help in trauma cases?
REBOA has a few potential advantages to consider in pre-hospital trauma cases:
- For prevention: Severe hemorrhage in trauma patients is a precursor to arrest. REBOA can help control hemorrhage and prevent cases of cardiogenic shock and cardiac arrest.
- To support efficient use of resources: In a time when blood products are in short supply and high demand, use of REBOA can support hemodynamic stability and help avoid waste of blood products.
- In specific patient populations: REBOA may also have potential as a supportive procedure for certain populations, such as Jehovah’s Witnesses, who refuse the use of blood products.
Research on REBOA
From 2014 to 2018, a United Kingdom study examined the use of pre-hospital REBOA for patients with hemorrhagic trauma to the pelvis who were exsanguinating in the field.2 The REBOA technique was performed by a physician-lead team, and the study used the following criteria for determining use of REBOA3:
- Crushing or penetrating pelvic injury
- Injuries of the vasculature consistent with exsanguination
- Rapid evolution of shock state
- Inclusion of the “hateful eight” signs: pale, clammy, air hungry, venous collapse, hypotension, low/dropping end-tidal carbon dioxide, tachycardia or bradycardia, altered mental state
Results were promising, showing a significant improvement of blood pressures in the field, which decreased hypovolemia leading to cardiac arrest.2
Current and future use of REBOA
Current use of REBOA
REBOA is more common in the European Union (EU) than in the United States. In the EU, it’s been used as far back as 2005 as a bridge to surgical intervention to prevent exsanguination leading to cardiac arrest.4 In the United States, REBOA is performed by emergency medicine physicians, and most protocols also include the need for access to surgical intervention. That’s because REBOA is a temporary — not definitive — measure to control hemorrhage.5
Future use of REBOA
Success with REBOA is highly dependent on physician skills, comfort with catheter placement, and close access to a hospital with surgical and interventional support. And it’s not without risk of complications. So what would it take to expand the use of REBOA in the United States?
- Additional high-grade evidence to guide its use, along with standardization of processes to fully support trauma patients.5
- Training for emergency medicine physicians. Especially if not used properly, REBOA includes risk of complications (e.g., femoral access complications, aortoiliac injuries, balloon rupture with over-inflation of the balloon).5 Proper training is essential.
- More robust credentialing and certification requirements to ensure providers are capable and prepared to perform REBOA.
RELATED ARTICLES
Keep learning
For more insight into emerging trends in trauma resuscitation, check out our article on the use of tranexamic acid to control hemorrhage in trauma patients.
References
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Jansen J, Cochran C, Boyers D, et al. (2022.) The effectiveness and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma patients with uncontrolled torso haemorrhage: study protocol for a randomised clinical trial (the UK-REBOA trial). Trials, 23(1):384. https://doi.org/10.1186/s13063-022-06346-1
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Lendrum R, Perkins Z, Chana M, et al. (2019a). Pre-hospital resuscitative endovascular balloon occlusion of the aorta (reboa) for exsanguinating pelvic haemorrhage. Resuscitation, 135, 6–13. https://doi.org/10.1016/j.resuscitation.2018.12.018
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Lendrum R, Perkins Z , Chana M, et al (2019c). Reply to: Prehospital reboa: Time to clearly define the relevant indications. Resuscitation, 142, 191–192. https://doi.org/10.1016/j.resuscitation.2019.05.031
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Malina M, Veith F, Ivancev K, Sonesson B. (2005). Balloon occlusion of the aorta during endovascular repair of ruptured abdominal aortic aneurysm. Journal of Endovascular Therapy, 12(5), 556–559. https://doi.org/10.1583/05-1587.1
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Brenner M, Bulger EM, Perina DG, et al (2018). Joint statement from the american college of surgeons committee on trauma (acscot) and the american college of emergency physicians (acep) regarding the clinical use of resuscitative endovascular balloon occlusion of the aorta (reboa). Trauma Surgery & Acute Care Open, 3(1), e000154. https://doi.org/10.1136/tsaco-2017-000154
