We've discussed REBOA before on the EMCrit Podcast with Megan Brenner. We also featured the first prehospital REBOA case. It was an interesting treatment, but an extremely complex one. That has all changed with the new ER REBOA catheter.

In this podcast, I discuss the new catheter from Prytime and then I interview Dr. Joe DuBose, a trauma and vascular surgeon who performed the first ER REBOA placement that resulted in a survivor.

Conflicts of Interest

Neither Dr. DuBose nor I have any conflicts of interest regarding the ER REBOA catheter or otherwise

Slides from Dr. DuBose's Case

ER REBOA Visual Tour

ER REBOA Placement Video

Steps to Placement of the ER REBOA Catheter

Gain Access to the Common Femoral Artery with a 7-French Introducer

• Just like normal for an arterial line, except make sure you are hitting common femoral and not superficial femoral artery. The point of entry should be 2 cm below inguinal ligament (estimate ligament by anterior superior iliac to pubic tubercle). This may be much higher than you are used to.
• Only some introducers will work:
  

Attach a Syringe to the Balloon Port of the REBOA Catheter

• Use a 25 or 30 ml syringe, filled with 24 ml of NS

Test the Balloon

• Inflate to test patency
• Make sure to fully deflate the balloon. Apply some extra suction to really shrink it down and then lock the balloon stopcock

Attach Transducer

• Attach a pressure transducer to the arterial line port. Zero the transducer to the phlebostatic access

Measure externally

• Zone 1 is measured with the proximal edge of the balloon at the xiphoid, Zone 3 is measured with the proximal edge of the balloon just above the umbilicus.

Insert the REBOA Catheter

• Use the orange sheath to straighten the p-tip
• Insert the orange sheath 1cm into the valve of the 7-french introducer
• Advance the REBOA catheter a few cm into the introducer
• Pull back on the orange sheath
• Advance the REBOA catheter to the predetermined depth

Inflate the Balloon

• Hold the REBOA catheter to prevent it from pushing out
• Open the Stopcock
• Inflate until resistance goes to moderate or the blood pressure on the arterial line tracing of the REBOA Catheter starts to increase. 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 inflation is far harder than you may think. For me, it is the maximal force I can apply with 1 hand.
• Never instill more than 24 mls. Never more than 24
• Close the stopcock

Secure the Catheter

• If the catheter is not secured externally it will migrate out from aortic pressure, especially in zone I
• It will be an institution dependent choice as to how to secure: tape, sutures, the wings from a 7-french triple lumen, etc.

Get an Xray when time allows

Go to Definitive Management

• When deflating the balloon for removal, it will require active suction to cause deflation. Make sure the number of mls recorded as being used for inflation are removed. If the catheter catches on the introducer sheath during removal, reinsert a few cm. Gently inflate with a few mls and then remove all saline again and maintain suction while locking the stopcock.
• The introducer sheath removal likely will not need cutdown or arterial repair. However, patients are still at risk for vascular trauma or vasospasm.
• Schedule neurovascular checks and consider angiographic imaging.

Even More Stuff

• In a delightful bit of synchronicity, my main man Rob Orman, published a REBOA podcast yesterday with Zaf
• Zaf's REBOA Review Article
• Deb Stein on REBOA from SmaccCHICAGO
• History of REBOA (J Trauma Acute Care Surg 79(4-supp 1):S236
• REBOA Case Series
• Trauma Registry Study (Journal of Trauma and Acute Care Surgery:October 2015 – Volume 79 – Issue 4 – p 523–532)
• Ultrasound Wire Confirmation (Journal of Trauma and Acute Care Surgery October 2015 – Volume 79 – Issue 4 – p 549–554)
• Ultrasonography technique for Zone III (J Trauma Acute Care Surg 2016;80: 89)
• Resuscitative endovascular balloon occlusion of the aorta for uncontrolled haemorrahgic shock as an adjunct to haemostatic procedures in the acute care setting
• A cadaver study indicates mid-sternum may be a better landmark (Journal of Trauma and Acute Care Surgery:
  September 2016 – Volume 81 – Issue 3 – p 453–457)
• A micro-bubble ultrasound contrast agent may further augment the ultrasound visualization (DOI: 10.1097/TA.0000000000000863)
• First study of ER-REBOA in combat. placed by non-surgeons (PMID: 28285473)

Now on to the Podcast…

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Scott Weingart

Editor-in-Chief, EMCrit.org at EDECMO LLC

An ED Intensivist from NY. No conflicts of interest (coi).

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