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Foley MP, Walsh SR, Doolan N, Vulliamy P, McMonagle M, Aylwin C. Editor's Choice - Systematic Review and Meta-Analysis of Lower Extremity Vascular Complications after Arterial Access for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): An Inevitable Concern? Eur J Vasc Endovasc Surg 2023; 66:103-118. [PMID: 36796674 DOI: 10.1016/j.ejvs.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/24/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporise non-compressible torso haemorrhage. Recent data have suggested that vascular access complications secondary to REBOA placement are higher than initially anticipated. This updated systematic review and meta-analysis aimed to determine the pooled incidence rate of lower extremity arterial complications after REBOA. DATA SOURCES PubMed, Scopus, Embase, conference abstract listings, and clinical trial registries. REVIEW METHODS Studies including more than five adults undergoing emergency REBOA for exsanguinating haemorrhage that reported access site complications were eligible for inclusion. A pooled meta-analysis of vascular complications was performed using the DerSimonian-Laird weights for the random effects model, presented as a Forest plot. Further meta-analyses compared the relative risk of access complications between different sheath sizes, percutaneous access techniques, and indications for REBOA. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. RESULTS No randomised controlled trials were identified, and the overall study quality was poor. Twenty-eight studies including 887 adults were identified. REBOA was performed for trauma in 713 cases. The pooled proportion rate of vascular access complications was 8.6% (95% confidence interval 4.97 - 12.97), with substantial heterogeneity (I2 = 67.6%). There was no significant difference in the relative risk of access complications between 7 and > 10 F sheaths (p = .54), or between ultrasound guided and landmark guided access (p = .081). However, traumatic haemorrhage was associated with a significantly higher risk of complications compared with non-traumatic haemorrhage (p = .034). CONCLUSION This updated meta-analysis aimed to be as comprehensive as possible considering the poor quality of source data and high risk of bias. It suggested that lower extremity vascular complications were higher than originally suspected after REBOA. While the technical aspects did not appear to impact the safety profile, a cautious association could be drawn between REBOA use for traumatic haemorrhage and a higher risk of arterial complications.
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Affiliation(s)
- Megan Power Foley
- Department of Vascular Surgery, University College Hospital Galway, Galway, Ireland; Blizard Institute for Trauma Sciences, Queen Mary University of London, London, UK.
| | - Stewart R Walsh
- Lambe Institution for Translational Research, National University of Ireland Galway, Galway, Ireland; National Surgical Research Support Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Nathalie Doolan
- Department of Vascular Surgery, University College Hospital Galway, Galway, Ireland
| | - Paul Vulliamy
- Blizard Institute for Trauma Sciences, Queen Mary University of London, London, UK
| | | | - Christopher Aylwin
- Blizard Institute for Trauma Sciences, Queen Mary University of London, London, UK; Department of Trauma Surgery, Imperial College London, London, UK
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Intermittent thoracic resuscitative endovascular balloon occlusion of the aorta improves renal function compared to 60 min continuous application after porcine class III hemorrhage. Eur J Trauma Emerg Surg 2022; 49:1303-1313. [DOI: 10.1007/s00068-022-02189-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may be considered for stabilization of patients with hemorrhage from below the diaphragm. Occluding the aorta is a powerful means of hemorrhagic control but is also associated with acute kidney injury, which increases mortality in trauma patients. Allowing for intermittent distal blood flow during REBOA application (iREBOA) could decrease this risk, but circulatory consequences have not been sufficiently elucidated. Therefore, we investigated circulatory effects and the renal artery blood flow (RBF) in iREBOA versus continuous, complete aortic occlusion (cREBOA).
Methods
In a porcine model of uncontrolled class III hemorrhage (34% estimated total blood volume, mean 1360 mL), swine (n = 12, mean weight 60.3 kg) were randomly assigned to iREBOA: 3-min full deflation every 10 min (n = 6), or cREBOA (n = 6), for 60 min of thoracic (zone I) application. The animals then underwent 60 min of reperfusion (critical care phase).
Results
Survival was 100% in iREBOA and 83% in cREBOA. The intermittent balloon deflation protocol was hemodynamically tolerable in 63% of reperfusion intervals. Systolic blood pressure decreased during the reperfusion intervals in iREBOA animals (mean 108 mm Hg versus 169 mm Hg; p < 0.005). No differences were detected in heart rate, cardiac output or stroke volume between methods. Troponin I increased in cREBOA after 60 min (mean 666–187 ng/L, p < 0.05). The norepinephrine requirement increased in cREBOA during reperfusion (mean infusion time 12.5–5.5 min; p < 0.05). Total ischemic time decreased in iREBOA (60.0–48.6 min; p < 0.001). RBF increased in iREBOA during balloon deflations and after 60 min reperfusion (61%–39% of baseline RBF; p < 0.05). Urine output increased in iREBOA (mean 135–17 mL; p < 0.001). Nephronal osteopontin, a marker of ischemic injury, increased in cREBOA (p < 0.05).
Conclusion
iREBOA was survivable, did not cause rebleeding, decreased the total ischemic time and increased the renal blood flow, urine output and decreased renal ischemic injury compared to cREBOA. Intermittent reperfusions during REBOA may be preferred to be continuous, complete occlusion in prolonged application to improve renal function.
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Aoki M, Abe T. Traumatic Cardiac Arrest: Scoping Review of Utilization of Resuscitative Endovascular Balloon Occlusion of the Aorta. Front Med (Lausanne) 2022; 9:888225. [PMID: 35783650 PMCID: PMC9243328 DOI: 10.3389/fmed.2022.888225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/26/2022] [Indexed: 12/05/2022] Open
Abstract
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is increasingly used in trauma resuscitation for patients with life-threatening hemorrhage below the diaphragm and may also be used for patients with traumatic cardiac arrest (TCA). Resuscitative thoracotomy with aortic cross clamping (RT-ACC) maneuver was traditionally performed for patients with TCA due to hemorrhagic shock; however, REBOA has been substituted for RT-ACC in selected TCA cases. During cardiopulmonary resuscitation (CPR) in TCA, REBOA increases cerebral and coronary perfusion, and temporary bleeding control. Both animal and clinical studies have reported the efficacy of REBOA for TCA, and a recent observational study suggested that REBOA may contribute to the return of spontaneous circulation after TCA. Although multiple questions remain unanswered, REBOA has been applied to trauma fields as a novel technology.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
- *Correspondence: Makoto Aoki
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
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The Role of Prehospital REBOA for Hemorrhage Control in Civilian and Military Austere Settings: A Systematic Review. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite the success of prehospital resuscitative endovascular balloon occlusion of the aorta (REBOA) in combat and civilian settings, the prevalence of complications and the lack of conclusive evidence has led to uncertainty and controversy. Therefore, this systematic review aimed to evaluate the role of prehospital REBOA for hemorrhage control in trauma populations. We systematically searched Cochrane, Ovid MEDLINE, EMBASE and Google Scholar for all relevant studies that investigated the efficacy of prehospital REBOA on trauma patients with massive hemorrhage. Primary outcome was evaluated by blood pressure elevation and secondary outcome was measured by 30-day mortality and complications. Our search identified 546 studies, but only six studies met the inclusion and exclusion criteria. Included studies were low to moderate quality due to limitations within the studies. However, all of the studies reported significant elevation of blood pressure and survival, demonstrating the potential benefits of REBOA. For example, the 30-day mortality rate reduced significantly after REBOA, but studies lacked long-term outcome assessments across the continuum of care. Due to the heterogeneity of the results, a meta-analysis was not possible. We conclude that prehospital REBOA is a feasible and effective resuscitative adjunct for shock patients with lethal non-compressible torso hemorrhage. However, due to the unclear causes of complications and the lack of high quality and homogeneous data, the effects of prehospital REBOA were not truly reflected and comparison between groups was not feasible. Thus, further high-quality studies are required to attest the causality between prehospital REBOA and outcomes.
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Shi C, Li S, Wang Z, Shen H. Prehospital aortic blood flow control techniques for non-compressible traumatic hemorrhage. Injury 2021; 52:1657-1663. [PMID: 33750584 DOI: 10.1016/j.injury.2021.02.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
Non-compressible hemorrhage in the junctional areas and torso could be life-threatening and its prehospital control remains extremely challenging. The aim of this review was to compare commonly used techniques for the control of non-compressible hemorrhage in prehospital settings, and thereby provide evidence for further improvements in emergency care of traumatic injuries. Three techniques were reviewed including external aortic compression (EAC), abdominal aortic junctional tourniquet (AAJT), and resuscitative endovascular balloon occlusion of the aorta (REBOA). In prehospital settings, all three techniques have demonstrated clinical effectiveness for the control of severe hemorrhage. EAC is a cost- and equipment-free, easy-to-teach, and immediately available technique. In contrast, AAJT and REBOA are expensive and require detailed instructions or systematic training. Compared with EAC, AAJT and REBOA have greater potentials in the management of traumatic hemorrhage. AAJT can be used not only in the junctional areas but also in pelvic and bilateral lower limb injuries. However, both AAJT and REBOA should be used for a limited time (less than 1 hour) due to possible consequences of ischemia and reperfusion. Compared with EAC and AAJT, REBOA is invasive, requiring femoral arterial access and intravascular guidance and inflation. Mortality from non-compressible hemorrhage could be reduced through the prehospital application of aortic blood flow control techniques. EAC should be considered as the first-line choice for many non-compressible injuries that cannot be managed with conventional junctional tourniquets. In comparison, AAJT or REBOA is recommended for better control of the aorta blood flow in prehospital settings. Although these three techniques each have advantages, their use in trauma is not widespread. Future studies are warranted to provide more data about their safety and efficacy.
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Affiliation(s)
- Changgui Shi
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China; Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Song Li
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China; Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhinong Wang
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Hongliang Shen
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China.
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A meta-analysis of the incidence of complications associated with groin access after the use of resuscitative endovascular balloon occlusion of the aorta in trauma patients. J Trauma Acute Care Surg 2019; 85:626-634. [PMID: 29787536 DOI: 10.1097/ta.0000000000001978] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Serious complications related to groin access have been reported with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA). We performed a systematic review and meta-analysis to estimate the incidence of complications related to groin access from the use of REBOA in adult trauma patients. METHODS We identified articles in MEDLINE and EMBASE. We reviewed all studies that involved adult trauma patients who underwent the placement of a REBOA and included only those that reported the incidence of complications related to groin access. A meta-analysis of proportions was performed. RESULTS We identified 13 studies with a total of 424 patients. REBOA was inserted most commonly by trauma surgeons or emergency room physicians. Information regarding puncture technique was reported in 12 studies and was available for a total of 414 patients. Percutaneous access and surgical cutdown were performed in 304 (73.4%) and 110 (26.5%) patients, respectively. Overall, complications related to groin access occurred in 5.6% of patients (n = 24/424). Lower limb amputation was required in 2.1% of patients (9/424), of which three cases (3/424 [0.7%]) were directly related to the vascular puncture from the REBOA insertion. A meta-analysis that used the logit transformation showed a 5% (95% CI 3%-9%) incidence of complications without significant heterogeneity (LR test: χ = 0.73, p = 0.2, Tau-square = 0.2). In a second meta-analysis, we used the Freeman-Tukey double arcsine transformation and found an incidence of complications of 4% (95% CI 2%-7%) with low heterogeneity (I = 16.3%). CONCLUSION We found that the incidence of complications related to groin access was of 4-5% based on a meta-analysis of 13 studies published worldwide. Currently, there are no benchmarks or quality measures as a reference to compare, and thus, further work is required to identify these benchmarks and improve the practice of REBOA in trauma surgery. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
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Li Y, Chen L, Fang W, Chen H. Application value of procalcitonin, C-reactive protein and interleukin-6 in the evaluation of traumatic shock. Exp Ther Med 2019; 17:4586-4592. [PMID: 31086589 PMCID: PMC6488981 DOI: 10.3892/etm.2019.7492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 04/02/2019] [Indexed: 12/13/2022] Open
Abstract
Procalcitonin (PCT), C-reactive protein (CRP) and interleukin-6 (IL-6) were detected to explore the value of these inflammatory markers in the assessment of traumatic shock patients. The clinical data of 80 patients with traumatic shock and infections in Zhangzhou Municipal Hospital of Fujian Province from January 2014 to December 2017 were collected as the experimental group. During the same period, 80 acute trauma patients who did not suffer from traumatic shock were regarded as the control group. According to the prognosis outcomes, the experimental group was divided into 56 patients with good prognosis and 24 patients with poor prognosis. Also the PCT, CRP and IL-6 levels in serum of patients at admission (T1), 12 h after admission (T2), three days after admission (T3) and on day 7 (T4) were detected. The differences between the three inflammatory indicators, the pre-admission injury severity score (ISS score), the acute physiology and chronic psychological score (APACHE II score) were compared between the good prognosis and the poor prognosis group. The serum CRP at the T4 time period was significantly lower than both the T1 and T2 time periods (P<0.05). There were differences in serum PCT, CRP and IL-6 between the good prognosis and the poor prognosis group at the time of T1-T4 (P<0.05). The expression levels of PCT, CRP and IL-6 in the serum of patients with poor prognosis were higher than those with good prognosis (P<0.05). Pre-admission ISS scores and APACHE II scores in patients with good prognosis were lower than those with poor prognosis (P<0.05). Detection of PCT, CRP and IL-6 expression levels in serum of the patients has an important reference value for assessing the condition of patients with traumatic shock.
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Affiliation(s)
- Yang Li
- Department of Emergency, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian 363000, P.R. China
| | - Ling Chen
- Department of Emergency, Zhangzhou Municipal Hospital of Fujian Province, Zhangzhou, Fujian 363000, P.R. China
| | - Wenge Fang
- Department of Emergency, Zhangzhou Municipal Hospital of Fujian Province, Zhangzhou, Fujian 363000, P.R. China
| | - Huihong Chen
- Department of Emergency, Zhangzhou Municipal Hospital of Fujian Province, Zhangzhou, Fujian 363000, P.R. China
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Bekdache O, Paradis T, Shen YBH, Elbahrawy A, Grushka J, Deckelbaum D, Khwaja K, Fata P, Razek T, Beckett A. Resuscitative endovascular balloon occlusion of the aorta (REBOA): indications: advantages and challenges of implementation in traumatic non-compressible torso hemorrhage. Trauma Surg Acute Care Open 2019; 4:e000262. [PMID: 31245615 PMCID: PMC6560484 DOI: 10.1136/tsaco-2018-000262] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is regaining popularity in the treatment of traumatic non-compressible torso bleeding. Advances in invasive radiology coupled with new damage control measures assisted in the refinement of the technique with promising outcomes. The literature continues to have substantial heterogeneity about REBOA indications, applications, and the challenges confronted when implementing the technique in a level I trauma center. Scoping reviews are excellent platforms to assess the diverse literature of a new technique. It is for the first time that a scoping review is adopted for this topic. Advances in invasive radiology coupled with new damage control measures assisted in the refinement of the technique with promising outcomes. The literature continues to have substantial heterogeneity about REBOA indications, applications, and the challenges confronted when implementing the technique in a level I trauma center. Scoping reviews are excellent platforms to assess the diverse literature of a new technique. It is for the first time that a scoping review is adopted for this topic. Methods Critical search from MEDLINE, EMBASE, BIOSIS, COCHRANE CENTRAL, PUBMED and SCOPUS were conducted from the earliest available dates until March 2018. Evidence-based articles, as well as gray literature at large, were analyzed regardless of the quality of articles. Results We identified 1176 articles related to the topic from all available database sources and 57 reviews from the gray literature search. The final review yielded 105 articles. Quantitative and qualitative variables included patient demographics, study design, study objectives, methods of data collection, indications, REBOA protocol used, time to deployment, zone of deployment, occlusion time, complications, outcome, and the level of expertise at the concerned trauma center. Conclusion Growing levels of evidence support the use of REBOA in selected indications. Our data analysis showed an advantage for its use in terms of morbidities and physiologic derangement in comparison to other resuscitation measures. Current challenges remain in the selective application, implementation, competency assessment, and credentialing for the use of REBOA in trauma settings. The identification of the proper indication, terms of use, and possible advantage of the prehospital and partial REBOA are topics for further research. Level of evidence Level III.
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Affiliation(s)
- Omar Bekdache
- Department of Trauma and Acute Care Surgery, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Surgery, Tawam Hospital - Johns Hopkins, Al Ain, Abu Dhabi, United Arab Emirates
| | - Tiffany Paradis
- Department of Surgery, McGill University Faculty of Medicine, Montreal, Quebec, Canada
| | - Yu Bai He Shen
- Department of Surgery, McGill University Faculty of Medicine, Montreal, Quebec, Canada
| | - Aly Elbahrawy
- Department of Trauma and Acute Care Surgery, McGill University Health Centre, Montreal, Quebec, Canada.,Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Jeremy Grushka
- Department of Trauma and Acute Care Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dan Deckelbaum
- Department of Trauma and Acute Care Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kosar Khwaja
- Department of Trauma and Acute Care Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Paola Fata
- Department of Trauma and Acute Care Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tarek Razek
- Department of Trauma and Acute Care Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew Beckett
- Department of Trauma and Acute Care Surgery, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Surgery, Royal Canadian Medical Services, Montreal, Quebec, Canada
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Osborn LA, Brenner ML, Prater SJ, Moore LJ. Resuscitative endovascular balloon occlusion of the aorta: current evidence. Open Access Emerg Med 2019; 11:29-38. [PMID: 30666171 PMCID: PMC6336022 DOI: 10.2147/oaem.s166087] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently gained popularity as a minimally invasive alternative to open aortic cross-clamping in the management of patients with non-compressible hemorrhage arising below the diaphragm. The purpose of this review is to provide a description of the technical aspects of REBOA use along with an overview of the current animal and clinical data regarding its use.
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Affiliation(s)
- Lesley A Osborn
- Department of Emergency Medicine, The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA,
| | - Megan L Brenner
- Department of Surgery, The University of California - Riverside, Moreno Valley, CA, USA
| | - Samuel J Prater
- Department of Emergency Medicine, The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA,
| | - Laura J Moore
- Department of Surgery, The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA
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Goforth C, Bradley M, Pineda B, See S, Pasley J. Resuscitative Endovascular Balloon Occlusion of the Aorta: A Bridge to Flight Survival. Crit Care Nurse 2018; 38:69-75. [PMID: 29606678 DOI: 10.4037/ccn2018853] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Trauma endures as the leading cause of death worldwide, and most deaths occur in the first 24 hours after initial injury as a result of hemorrhage. Historically, about 90% of battlefield deaths occur before the injured person arrives at a theater hospital, and most are due to noncompressible hemorrhage of the torso. Resuscitative endovascular balloon occlusion of the aorta is an evolving technique to quickly place a balloon into the thoracic or abdominal aorta to efficiently block blood flow to distal circulation. Maneuvers, such as resuscitative endovascular balloon occlusion of the aorta, to control endovascular hemorrhage offer a potential intervention to control noncompressible hemorrhage. This technique can be performed percutaneously or open in prehospital environments to restore hemodynamic functions and serve as a survival bridge until the patient is delivered to a treatment facility for definitive surgical hemostasis. This article describes the indications, complications, and application of resuscitative endovascular balloon occlusion of the aorta to military and civilian aeromedical transport.
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Affiliation(s)
- Carl Goforth
- CDR Carl Goforth, NC, USN, is a nurse researcher, Naval Medical Research Center, Silver Spring, Maryland, and Uniformed Services University of the Health Sciences, Bethesda, Maryland. .,CDR Matthew Bradley, NC, USN, is a staff surgeon at Walter Reed National Military Medical Center, Bethesda, Maryland, and is conducting research on resuscitation at the Naval Medical Research Center, Silver Spring, Maryland. .,MAJ Benilani Pineda, ANC, USA, is the former director, Joint En Route Care Course, Fort Rucker, Alabama. She is currently serving in the National Capital Region, US Army Executive Medicine, Washington, DC. .,Maj Suzanne See, USAF, NC, is a trauma educator at the Center for the Sustainment of Trauma and Readiness Skills, R. Adams Crowley Shock Trauma Center, Baltimore, Maryland. .,Lt Col Jason Pasley, USAF, MC, a board-certified trauma surgeon, is the director of physician education at the Center for the Sustainment of Trauma and Readiness Skills, R. Adams Crowley Shock Trauma Center. He also is a core faculty member of the American College of Surgeons basic endovascular skills for trauma course.
| | - Matthew Bradley
- CDR Carl Goforth, NC, USN, is a nurse researcher, Naval Medical Research Center, Silver Spring, Maryland, and Uniformed Services University of the Health Sciences, Bethesda, Maryland.,CDR Matthew Bradley, NC, USN, is a staff surgeon at Walter Reed National Military Medical Center, Bethesda, Maryland, and is conducting research on resuscitation at the Naval Medical Research Center, Silver Spring, Maryland.,MAJ Benilani Pineda, ANC, USA, is the former director, Joint En Route Care Course, Fort Rucker, Alabama. She is currently serving in the National Capital Region, US Army Executive Medicine, Washington, DC.,Maj Suzanne See, USAF, NC, is a trauma educator at the Center for the Sustainment of Trauma and Readiness Skills, R. Adams Crowley Shock Trauma Center, Baltimore, Maryland.,Lt Col Jason Pasley, USAF, MC, a board-certified trauma surgeon, is the director of physician education at the Center for the Sustainment of Trauma and Readiness Skills, R. Adams Crowley Shock Trauma Center. He also is a core faculty member of the American College of Surgeons basic endovascular skills for trauma course
| | - Benilani Pineda
- CDR Carl Goforth, NC, USN, is a nurse researcher, Naval Medical Research Center, Silver Spring, Maryland, and Uniformed Services University of the Health Sciences, Bethesda, Maryland.,CDR Matthew Bradley, NC, USN, is a staff surgeon at Walter Reed National Military Medical Center, Bethesda, Maryland, and is conducting research on resuscitation at the Naval Medical Research Center, Silver Spring, Maryland.,MAJ Benilani Pineda, ANC, USA, is the former director, Joint En Route Care Course, Fort Rucker, Alabama. She is currently serving in the National Capital Region, US Army Executive Medicine, Washington, DC.,Maj Suzanne See, USAF, NC, is a trauma educator at the Center for the Sustainment of Trauma and Readiness Skills, R. Adams Crowley Shock Trauma Center, Baltimore, Maryland.,Lt Col Jason Pasley, USAF, MC, a board-certified trauma surgeon, is the director of physician education at the Center for the Sustainment of Trauma and Readiness Skills, R. Adams Crowley Shock Trauma Center. He also is a core faculty member of the American College of Surgeons basic endovascular skills for trauma course
| | - Suzanne See
- CDR Carl Goforth, NC, USN, is a nurse researcher, Naval Medical Research Center, Silver Spring, Maryland, and Uniformed Services University of the Health Sciences, Bethesda, Maryland.,CDR Matthew Bradley, NC, USN, is a staff surgeon at Walter Reed National Military Medical Center, Bethesda, Maryland, and is conducting research on resuscitation at the Naval Medical Research Center, Silver Spring, Maryland.,MAJ Benilani Pineda, ANC, USA, is the former director, Joint En Route Care Course, Fort Rucker, Alabama. She is currently serving in the National Capital Region, US Army Executive Medicine, Washington, DC.,Maj Suzanne See, USAF, NC, is a trauma educator at the Center for the Sustainment of Trauma and Readiness Skills, R. Adams Crowley Shock Trauma Center, Baltimore, Maryland.,Lt Col Jason Pasley, USAF, MC, a board-certified trauma surgeon, is the director of physician education at the Center for the Sustainment of Trauma and Readiness Skills, R. Adams Crowley Shock Trauma Center. He also is a core faculty member of the American College of Surgeons basic endovascular skills for trauma course
| | - Jason Pasley
- CDR Carl Goforth, NC, USN, is a nurse researcher, Naval Medical Research Center, Silver Spring, Maryland, and Uniformed Services University of the Health Sciences, Bethesda, Maryland.,CDR Matthew Bradley, NC, USN, is a staff surgeon at Walter Reed National Military Medical Center, Bethesda, Maryland, and is conducting research on resuscitation at the Naval Medical Research Center, Silver Spring, Maryland.,MAJ Benilani Pineda, ANC, USA, is the former director, Joint En Route Care Course, Fort Rucker, Alabama. She is currently serving in the National Capital Region, US Army Executive Medicine, Washington, DC.,Maj Suzanne See, USAF, NC, is a trauma educator at the Center for the Sustainment of Trauma and Readiness Skills, R. Adams Crowley Shock Trauma Center, Baltimore, Maryland.,Lt Col Jason Pasley, USAF, MC, a board-certified trauma surgeon, is the director of physician education at the Center for the Sustainment of Trauma and Readiness Skills, R. Adams Crowley Shock Trauma Center. He also is a core faculty member of the American College of Surgeons basic endovascular skills for trauma course
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