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01/10/2015

Breaking News: REBOA Gaining Traction as ED Treatment

Emergency Medicine News | Shaw, Gina

In a battlefield hospital in Korea more than five decades ago, a surgeon fought to save the lives of three critically injured soldiers who were bleeding out. With nothing to lose, he tried a never-before-attempted technique: threading a balloon catheter through the femoral artery into the thoracic portion of each soldier’s aorta and inflating the balloon to occlude blood flow and increase life-sustaining blood pressure and perfusion to the heart and brain.

One of the soldiers, for whom the surgeon did not have time to attempt the technique, died almost immediately. The other two survived long enough with endovascular occlusion of the aorta to undergo open surgical repair of obvious abdominal damage, although they later died from their injuries. A 1954 article describes this first-of-its-kind case series by the surgeon, then-Lieutenant Colonel Carl Hughes, MD, a pioneer in arterial repair who ultimately rose to the rank of Major General and Chief of Surgery at Walter Reed Army Medical Center in Bethesda, MD. He theorized that earlier intervention with the technique might have improved the men’s chances of survival. (Surgery 1954;36[1]:65.)

Decades after Dr. Hughes’ desperate experiment, catheter-based techniques, also referred to as endovascular techniques, exploded onto the medical scene for managing age-related vascular disease. For the better part of the 1980s, 1990s, and 2000s, catheter-based diagnostic and therapeutic procedures were the purview of interventional cardiologists, radiologists, and recently vascular surgeons. Despite sporadic reports of endovascular techniques used in emergency settings for trauma and shock, use of these approaches has not been used outside of the operating room or specialized interventional radiology or cardiology suites.

This practice paradigm may be about to change, however. A revised approach to Dr. Hughes’ original procedure, resuscitative endovascular balloon occlusion of the aorta (REBOA), has gained new traction among trauma experts. Most agree that REBOA is not yet ready for prime time, though evidence from research studies and new technologies suggest REBOA will be coming to a trauma bay near you.

Noncompressible hemorrhage remains the leading cause of preventable death from trauma with mortality rates from intra-abdominal, pelvic, and groin hemorrhage approaching 50 percent. Underscoring the urgency to find better ways to manage this injury pattern, noncompressible bleeding in the torso has been labeled the leading cause of potentially preventable traumatic death in civilian and military settings. (Eur J Vasc Endovasc Surg 2012;44[2]:203.)

“We’ve known for ages that hemorrhage is a significant problem, and if left unattended, [it] leads to mortality or severe morbidity,” said Col. Todd Rasmussen, MD, the director of the U.S. Combat Casualty Care Research Program at Fort Detrick, MD, and the Harris B. Shumacker Jr. Professor of Surgery at the Uniformed Services University of the Health Sciences in Bethesda. “But the military’s prolonged experience with managing hemorrhagic shock during the recent long wars in Iraq and Afghanistan has provided new understanding of and placed a new focus on this significant problem in trauma and emergency medicine.”

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