REBOA as a New Damage Control Component in Hemodynamically Unstable Noncompressible Torso Hemorrhage Patients

Abstract

Noncompressible torso hemorrhage is one of the leading causes of preventable death worldwide. An efficient and appropriate evaluation of the trauma patient with ongoing hemorrhage is essential to avoid the development of the lethal diamond (hypothermia, coagulopathy, hypocalcemia, and acidosis). Currently, the initial management strategies include permissive hypotension, hemostatic resuscitation, and damage control surgery. However, recent advances in technology have opened the doors to a wide variety of endovascular techniques that achieve these goals with minimal morbidity and limited access. An example of such advances has been the introduction of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which has received great interest among trauma surgeons around the world due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology. This article aims to describe the experience earned in the use of REBOA in noncompressible torso hemorrhage patients. Our results show that REBOA can be used as a new component in the damage control resuscitation of the severely injured trauma patient. To this end, we propose two new deployment algorithms for hemodynamically unstable noncompressible torso hemorrhage patients: one for blunt and another for penetrating trauma. We acknowledge that REBOA has its limitations, which include a steep learning curve, its inherent cost and availability. Although to reach the best outcomes with this new technology, it must be used in the right way, by the right surgeon with the right training and to the right patient.

Damage control of peripheral vascular trauma - Don’t be afraid of axillary or popliteal fosses

“…Temporary bleeding control maneuvers should be performed which include: wound packing, direct manual pressure or tourniquet placement 18 . If the patient remains hemodynamically unstable despite initial resuscitation efforts, the placement of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) should be considered and placed as an adjuvant 19,20 . The patient should then be transferred to the operating/hybrid room immediately.…”

Damage control approach to refractory neurogenic shock: a new proposal to a well-established algorithm

“…Resuscitative endovascular balloon occlusion of the aorta (REBOA) is commonly used as an adjunct to resuscitation and bridge to definitive control of non-compressible torso hemorrhage in patients with hemorrhagic shock 4 , 5 . It has also been performed for patients with neurogenic shock to support the central aortic pressure necessary for cerebral, coronary, and spinal cord perfusion 6 .…”

“…Adicionalmente, la pérdida de la inervación simpática del corazón puede causar bradicardia e incapacidad para producir una respuesta taquicárdica a la hipotensión 3 . Los efectos fisiológicos del choque neurogénico usualmente se revierten con la reanimación hídrica inicial, seguida del uso prudente de vasopresores cuando éstos se requieren 4 , 5 . El objetivo de este artículo es proponer un algoritmo para el abordaje y manejo del choque neurogénico refractario, que incluye el uso del Balón de Resuscitación Endovascular de Oclusión Aortica (REBOA) en Zona III como estrategia para el control de daños.…”

Hemodynamically unstable non-compressible penetrating torso trauma: a practical surgical approach

“…Abdominal & Pelvic Area: An exploratory laparotomy should be performed to achieve immediate control of all ongoing surgical bleeding. In pelvic bleeding cases, the REBOA can be repositioned from Zone 1 to Zone 3 to diminish possible mesenteric ischemic time while achieving proximal control of hemorrhage 14,15 .…”