Resuscitative endovascular balloon of the aorta is feasible in penetrating chest trauma with major hemorrhage: Proposal of a new institutional deployment algorithm

Abstract

BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging option for hemorrhage control, but its use is limited in scenarios such as penetrating chest trauma. The aim of this study was to describe the use of REBOA as a resuscitative adjunct in these cases with major hemorrhage and to propose a new clinical management algorithm. METHODS This was a prospective, observational study conducted at a single Level I trauma center in Colombia. We included all patients older than 14 years with severe trauma who underwent REBOA from January 2015 to December 2019. Patients received REBOA if they were in hemorrhagic shock and were unresponsive to resuscitation. RESULTS A total of 56 patients underwent REBOA placement of which 37 had penetrating trauma and 23 had chest trauma. All patients were hemodynamically unstable upon arrival to the emergency department, with a median systolic blood pressure of 69 mm Hg (interquartile range [IQR], 57–90 mm Hg) and median Injury Severity Score was 25 (IQR, 25–41). All REBOAs were deployed and inflated in zone 1, median inflation time was 40 minutes (IQR, 26–55 minutes), and no adverse neurologic outcomes were observed. Fifteen patients had REBOA and a median sternotomy. Eleven patients had concomitant abdominal wounds. Overall mortality was 28.6%, and there was no significant difference between penetrating versus blunt trauma patients (21.6% vs. 42.1%, p = 0.11). The survival rate of thoracic injured patients was similar to the predicted survival (65.2% vs. 63.3%). CONCLUSION Resuscitative endovascular balloon occlusion of the aorta can be used safely in penetrating chest trauma, and the implementation of a REBOA management algorithm is feasible with a well-trained multidisciplinary team. LEVEL OF EVIDENCE Therapeutic, level V.

Damage control resuscitation: REBOA as the new fourth pillar

“…We propose a new paradigm "The Fourth Pillar": Permissive Hypotension, Hemostatic Resuscitation, Damage Control Surgery and REBOA ( Figure 6). To this point, we have extended the indications of REBOA use and have applied it to salvage patients with penetrating and blunt trauma not only of the abdomen and pelvis 40,44 but also of the chest which until our reported initial successful experience was considered a contraindication 42,46,[51][52][53] . However, we are not promoting its vast use for all trauma patients but instead its use in specific well indicated dire scenarios of hemodynamic instability from ongoing non-compressible torso hemorrhage and impending cardiac arrest 54 .…”

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

“…This is partly due to the increased rate of penetrating trauma (68%) that plagues our Colombian society, which is far higher than that of similar published series of 7 to 15% worldwide 21,22 . Also, our patients commonly arrive in severe hemorrhagic shock with a high associated Injury Severity Score (>25) which has made us push the envelope on its use and venture into applying it even in cases of penetrating thoracic trauma with excellent results 8 . In addition, we have created a novel two-team approach to caring for the critically ill trauma patient which allows one team to perform surgical exposures and definitive hemorrhage control, while the other team simultaneously manages the resuscitation including all aspects of REBOA.…”

“…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 [5][6][7] . An example of such advances has been the introduction of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which has received significant interest among trauma surgeons worldwide due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology 8 . This article aims to describe the experience earned in the use of REBOA in Noncompressible torso hemorrhage patients.…”

Prehospital Damage Control: The Management of Volume, Temperature…and Bleeding!

“…Finally, we must understand that time is essential in trauma and patients require aggressive and efficient management from the moment that injury occurs. To give our patients the best chance at survival, our trauma systems must be kept up-to-date with current technology, this is why, and especially for cases of long transfer time, we have to consider the implementation of some of these new techniques to improve patient outcomes 67,68 .…”