EMCrit Podcast 121 – REBOA

reboa

Today, I got to interview one of the superstars at Shock Trauma on REBOA (resuscitative endovascular balloon occlusion of the aorta).

Balloon occlusion of the aorta was first described in 1954 (Surgery 1954;36(1):65). Other older articles include (Ann Emerg Med 1986;15(12):1466, J Endovasc Ther 2000;7(1):1, Endovasc Ther 2005;12(5):556).

The Shock Trauma Center (STC) Approach to REBOA

Gain Access to the Common Femoral Artery with Femoral A-line Kit

  • Just like normal, except make sure you are hitting common femoral and not superficial femoral artery

Float the Wire

  • STC uses Boston Scientific Amplatz superstiff wires (0.035in/260 cm/straight tip)
  • Measure externally from the catheter to the umblicus and then up to the level of the 2nd rib–mark this level on the wire
  • Advance the wire floppy-end first to the marked depth
  • Confirm location with either radiograph or fluoro before proceeding

Place the Sheath

  • At STC, they use a Check-Flo Performer Introducer (12 fr, 30cm)
  • Remove the femoral artery catheter
  • Measure the introducer externally from groin to just below the umbilicus
  • Dilate the vessel to accept the introducer
  • Place the introducer to the previously marked level

Place the Coda Catheter/Balloon

  • Grab a CODA balloon catheter (32 mm-balloon)
  • Measure externally; Zone 1 is measured to the xiphoid, Zone 3 is measured to just above the umbilicus
zones-of-aorta

from J Trauma. 2011 Dec;71(6):1869-72

 

  • Remove all air from the balloon using saline syringe
  • Insert the CODA catheter
  • The wire stays stationary throughout

Inflate the Balloon

  • Use a 30 ml syringe, ideally filled with 20 ml of NS and 10 ml of omnipaque (lohexol); use just saline if contrast not available
  • Inflate until resistance goes to moderate (would love to know what luminal pressure this corresponds to). In general, this corresponds to 12-22 mls depending on the size of the aorta–but this must be individualized to the patient.

Secure Everything for Transport

  • Here’s how they do it at STC

reboa-securing

  • Mark the levels of everything so you can verify there has been no migration

Get an Xray when time allows

Balloon in Zone-3

Balloon in Zone-3

Balloon in Zone-1

Balloon in Zone-1

Go to Definitive Management

  • The introducer sheath will need to be removed under direct observation after cutdown, with arterial repair (at least until smaller catheters are developed)

Shock Trauma Center Protocol

stc-reboa-prot

REBOA Articles

REBOA review article (J Trauma. 2011 Dec;71(6):1869-72)

Case series: Martinelli T et al. J Trauma 2010 Apr;68(4):942-8

Case Series: Brenner M et al. J Trauma Acute Care Surg. 2013 Sep;75(3):506

Update: Dr. Brenner’s new article on training with a REBOA simulator (10.1097/TA.0000000000000310) and the ESTARs Course Curriculum

Now on to the Podcast…

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Comments

  1. It looks really exciting and I hope I get to use one one day but isn’t it just an intravascular MAST suit? I can’t remember why the MAST suit died; there was one hanging in the resus storeroom when I was an intern but it had a lot of dust on it already and it only got dusted off to be sent to a museum.

    I’m really interested to hear your thoughts on what will make REBOA more useful and enduring than the MAST suit. Obviously it is a lot more elegant and it allows access to the patient. Is there more than that?

    And are they getting trouble with the massive potassium/lactate/cytokine dump when they deflate? I’d love to know how much of an effect that has, whether it is more than theoretical, and how it is mitigated.

    • not quite understanding–nothing like a MAST suit which was created on the flawed concept of autotransfusion. Better to think of it as a intravascular aortic crossclamp.

      • Fair enough. Like I say, the MAST suit was just before my time. I had thought it squeezed until no blood got into the lower body but evidently it was just a venous squeeze?

        Still, the critical care adventure that follows on deflation of one of these balloons after an hour or so of inflation and distal ischaemia must be something. It will be fascinating to watch this technology develop.

      • Richard Schwartz says:

        The Abdominal Aortic and Junctional Tourniquet (AAJT) http://www.speeroptech.com/hemorrhage-control/ is another device that has a role in these patients. It was developed as a means to externally cross clamp the aorta at the level of the aortic bifurcation. This device is designed for military field use for penetrating pelvic trauma. This can be placed quickly in the unstable patient and provide initial hemostasis and provide a bridge for placement of the REBOA or definitive surgery.

        Richard Schwartz MD
        Chairman and Professor
        Emergency Medicine
        Georgia Regents University

  2. Ari Kestler says:

    Is there any role for US confirmation of adequate placement and inflation of balloon vs. XR? Have they tried visualizing balloon in aorta at STC?

    • Place catheter, inflate balloon then when ready & US confirms position of US, use shaken air/saline flush to check position like in echo US – real bush hospital check when no radio-opaque solution available – by the way UK London HEMS is trying this technique – check BBC website Regards

  3. Ari Kestler says:

    My Trauma group is interested in learning this (I’m hoping to get lucky and tag along). It looks like there is a training course: http://vascular-trauma.com/workinggroup.html

    Anyone have any more details? Or know of other training courses?

  4. Hey Scott…great article thanks! (Will reference it in my upcoming trauma update to the registrars).

    The video they showed at SMACC demonstrating its use real time was superb…and I understand they are now developing a fluoroscopy-free system??

    Great catching up on the Gold Coast…cheers!

  5. Jonathan Henglein PA says:

    Hey Scott, Great interview once again. Thanks also to Dr. Brenner (forgive me if that is not the correct spelling).

    I’ve mostly heard REBOA being suggested in patients in hemorrhagic shock after sustaining pelvic fractures and or positive FAST exams as a temporizing measure for either I.R. or O.R. I understand this and am looking forward to further use and further study. However Dr. Brenner alluded to its use in patients who “come in in full arrest”. Can you further explain which Traumatic arrest patient would have REBOA implemented at shock Trauma? Would they ONLY perform REBOA on penetrating abdominal wounds suspected of causing an arrest. Is there a role in blunt traumatic arrest based on E-FAST and clinical instability of the pelvis (as CXR and pelvis XR are not as practical in an arrest)? Are these only patients who loose vitals in front of us or even > 10 minutes out in the field? I also wonder how this changes the role of ED thoracotomy.

    I know the focus is to become familiar with REBOA but I have heard very little of its use in the traumatic arrest population and this interests me.

    Thanks,

    Jonathan Henglein PA

    • the role I see as ideal is the pulseless pt, with negative chest tube output who still has a beating heart on ultrasound. In these patients, they need volume and a crossclamp rather than what a thoracotomy may offer.

  6. Thomas Coombs says:

    Dr Thomas Coombs
    Rural Generalist Anaesthetist – North Queesnland Australia
    Hi Scott, this technique would be comforting to have in my quiver for torrentially bleeding post partum haemorrhage patients – is dr brenner considering extending her short course to aliens? I couldnt seen her contact details anywhere. Once comfortable with the technique then its use in arrest situation.

Trackbacks

  1. […] 2. Learn about REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) from Scott Weingart over at EMCrit http://emcrit.org/podcasts/reboa/ […]

  2. […] technique, but have a look at the Shock Trauma Center (STC) protocol on REBOA and the fantastic post and podcast by Scott […]

  3. […] and ongoing research by Kenji Inaba on EMRAP last November as well as a descriptive, procedural blog post on EMCrit in April. Interestingly, this technique was first described in the 1950s during resuscitative […]

  4. […] they have successfully performed the world’s first pre-hospital REBOA. For more on REBOA, see this EMCrit post and podcast. […]

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