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. The point of entry should be 2cm below inguinal ligament (estimate ligament by anterior superior iliac to pubic tubercle). This may be much higher than you are used to.
- Use either 18 arterial line set or Cook 5f Central Venous Cath (G02070)
Float the Wire
- STC uses Boston Scientific Amplatz superstiff wires (0.035in/260 cm/straight floppy tip)
- Measure externally from the catheter to the level of the 2nd rib–mark this level on the wire (At STC, they use Avery 5422 stickers)
- Advance the wire floppy-end first to the marked depth
- Confirm location with either radiograph or fluoro before proceeding
- Mark the proximal end of the wire with a pen on the sterile drape
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 (make sure you are measuring the catheter, not the dilator). Mark with a sticker
- In some cases, you need to dilate the vessel to accept the introducer; in most cases the internal dilator is sufficient
- Place the introducer to the previously marked level
- Critical Move: Removal of the dilator can screw everything up. The operator should lock the sideport of the dilator between their fingers and grip tight and with the other hand, hold the wire proximally. Allow assistant to pin and pull the dilator. If they mess up, you are still controlling the sheath and the wire. If some of the wire gets pulled, have your assistant reinsert without you letting go of sheath or wire.
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. Measure at the proximal portion of the balloon
- 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. The actual infaltion is far harder than you may think. For me, it is the maximal force I can apply with 1 hand.
Secure Everything for Transport
- Here's how they do it at STC
- Mark the levels of everything so you can verify there has been no migration
Get an Xray when time allows
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
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
2015 Review Article: Biffl Reboa Review and Brenner's and then Biffl's Responses
Update: Dr. Brenner's new article on training with a REBOA simulator [cite source='doi']10.1097/TA.0000000000000310[/cite] and the ESTARs Course Curriculum
Update: How should you bill? Possibilities include: 36140 Introducer into arterial system, 36200 Aortic Cath, 36245 Selective cath placement, Placement of IABP, Transcath occlusion vessel, non-neck, non-extremity
Retrospective Series (Journal of Trauma and Acute Care Surgery 2015;78(1):132–135)
Here about the first Prehospital Reboa
Additional New Information
More on EMCrit
EMCrit 170 – the ER REBOA Catheter with Joe DuBose(Opens in a new browser tab)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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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… Read more »
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.
MAST – Squeeze the blood out of the venous side to have it pour out the hole in the arterial side + make it difficult for you to breathe.
Thanks DocXology, now that’s an image that makes sense of it for me nicely.
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
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
yep! though landmarks should be fine for balloon. it is wire confirmation that seems to be an issue.
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?
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!
I found this interesting little tidbit online while researching REBOA for an upcoming trauma conference. Do we have an ETA for approval or any more information on this?
http://www.pryormedical.com/wp-content/uploads/2013/06/ER-REBOA-Highlight-Sheet.pdf
about 6 months (we hope); Megan Brenner is one of the drivers of this new technology and her thoughts are this will make the device ED and intensivist friendly.
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… Read more »
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.
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.
they are in the process of creating courses for the public–will put the info on the blog as soon as they are ready.
What are your thoughts on pre-hospital REBOA? is this something that we can expect to see/practical for medics to perform? How about the REBOA compared to AAJT (prehospital).
Thank you!
Closure can be performed with a proglide device to save cut down
thank you , Scott. excellent as always
I can not find the Level 1 trauma course I paid $79 to access. I have searched numerous ways. Can someone help this computer skills limited lady?