SGEM#258: REBOA, Re-Re-Re-REBOA

Date: May 23rd, 2019 Reference: Joseph et al. Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. JAMA Surgery March 2019. Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Virginia. This is Bob’s tenth visit to the SGEM. DISCLAIMER: THE VIEWS AND OPINIONS OF THIS PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US AIR FORCE. Case: You are working at a Level 1 Trauma Center and are alerted to an incoming Type A trauma. After donning your PPE (personal protective equipment) and greeting the trauma surgeon in your resuscitation bay, nursing delivers report that you are about to receive a 24-year-old male that was involved in an explosion that knocked the patient from their vehicle. They have an unstable pelvis and were intubated in the field for airway protection due to a low Glasgow Coma Scale (GCS) score.  Vitals are heart rate 112 bpm, blood pressure 110/60 mmHg, respiratory rate 16 bpm (intubated), oxygen saturation 94%, afebrile and the patient is four minutes from arrival.  You have a brief conversation with your trauma surgeon regarding these findings, and upon arrival of the patient, you note an intubated airway, equal bilateral breath sounds, and a rapid regular heart rate.  The patient’s eyes are closed and makes minimal movements with his extremities. Your surgeon rapidly asks for the REBOA kit and begins catheterization of the femoral artery while you have a professional yet rapid debate about the need to complete the primary survey and roll the patient to examine their back. Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) was first used 50 years ago in the Korean War but was not mentioned in emergency medicine literature until 1986.  Its use declined in the 1990s and early 2000s, but during the past decade, it has gained the attention of trauma surgeons in military and civilian settings, potentially due to advances in the technology and smaller catheter sizes. The evidence for REBOA is conflicting.  Animal studies have shown REBOA to temporize exsanguinating hemorrhage and to restore perfusion.  Some human studies [1,2] have shown benefit but a recent registry study from Japan [3] showed the use of REBOA associated with higher mortality.  The authors noted a lack of multi-institutional data at a national level regarding efficacy and safety of REBOA in the United States, which prompted their study. The American College of Emergency Physicians (ACEP) and American College of Surgeons Committee on Trauma (ACS COT) in 2018 put out a joint statement for the use of REBOA [4]. They discuss some general observations, indication for REBOA, and guidelines for REBOA use and implementation. ACEP and ACS COT also discuss the transfer, management, special circumstances (deployed military settings), training, credentialing and quality assurance of REBOA. Clinical Question: What are the outcomes of trauma patients after REBOA placement? Reference: Joseph et al. Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. JAMA Surgery March 2019. Population: All adult (over 18 years of age) patients in the ACS-TQIP database from 2015-2016. Exclusions: Patients who were dead on arrival, were transferred from other facilities, had missing physiological parameters, or who underwent resuscitative thoracotomy were excluded. Intervention: Patients who received REBOA within one hour of presentation to the emergency department Comparison: Patients who did not receive REBOA (matched in a 1:2 intervention to comparison group) Outcome: Primary Outcomes: Emergency department mortality, 24-hour mortality, and mortality after 24 hours Secondary Outcomes: Transfusion requirements at four hours and 24 hours after injury, in hospital complications (DVT, PE, CVA, MI, extremity compartment syndrome,