Could resuscitative endovascular balloon occlusion of the aorta improve survival among severely injured patients with post-intubation hypotension?

Abstract

Current literature shows the association of post-intubation hypotension and increased odds of mortality in critically ill non-trauma and trauma populations. However, there is a lack of research on potential interventions that can prevent or ameliorate the consequences of endotracheal intubation and thus improve the prognosis of trauma patients with post-intubation hypotension. This review paper hypothesizes that the deployment of REBOA among trauma patients with PIH, by its physiologic effects, will reduce the odds of mortality in this population. The objective of this paper is to review the current literature on REBOA and post-intubation hypotension, and, furthermore, to provide a rational hypothesis on the potential role of REBOA in severely injured patients with post-intubation hypotension.

Damage control resuscitation: REBOA as the new fourth pillar

“…• REBOA is not only a tool that aids in the control of hemorrhage, it is also a vital tool in the hemodynamic resuscitation of a severely injured patient allowing for the intravascular volumetric content to remain directed towards essential organs which include the brain and the heart 44,45 • REBOA is a dynamic tool that requires the placement and ongoing management by a skilled and well-trained surgeon [46][47][48] • REBOA poses a new paradigm shift in which soon after the initial ABCDE evaluation proposed by ATLS, an introducer sheath should be placed via the common femoral artery in the Trauma Bay / ER, which allows for immediate ongoing real time blood pressure monitoring of the hemodynamically unstable severely injured trauma patient and if indicated (SBP <70 mmHg) the placement of a REBOA with the aim of reducing cell injury and hemodynamic decompensation by early proximal control of the source of bleeding in both blunt and penetrating trauma 42,46,49,50 It is our belief that the classic description of DCR may be leaving out one other crucial arm that may interact positively with the other three. We propose a new paradigm "The Fourth Pillar": Permissive Hypotension, Hemostatic Resuscitation, Damage Control Surgery and REBOA ( Figure 6).…”

Use of REBOA in the universe of magical realism: a real-world review

“…Using REBOA for full aortic occlusion when there are injuries above the point of occlusion theoretically increases the bleeding rate from the injury. However, we deploy REBOA in these patients as a resuscitative tool which restores blood flow to essential organs -improving cardiac and cerebral perfusion and compensating for the loss of anesthetic-induced or PPVinduced reduction of mean systemic pressure and preload (24).…”

Western Trauma Association critical decisions in trauma: airway management in adult trauma patients

“… 24 25 Postintubation hypotension is associated with increased mortality in trauma patients. 26–28 For patients who arrive hemodynamically unstable or stable with a shock index >0.8, 29 30 several options for simultaneous resuscitation exist including early blood transfusion using a “circulation first” approach, 31 resuscitative endovascular balloon occlusion of the aorta, 32 and intravenous push-dose pressors. 33 34 In particular, if the airway can be maintained with basic maneuvers and the patient is oxygenating and ventilating, placement of a definitive airway with an endotracheal tube can be deferred until the hemodynamic status of the patient can be addressed.…”