REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is a procedure that involves placement of an endovascular balloon in the aorta to control hemorrhage and to augment afterload in traumatic arrest and hemorrhagic shock states. Evidence has show that REBOA tends to cause less physiological disturbance and has higher rates of technical success than aortic cross clamping that is commonly done with a thoracotomy.
Should be considered and performed in conjunction with the surgical tem
Anatomy (Aorta is divided into three seperate zones):
· Zone I: extends from the origin of the left subclavian artery to the coeliac artery (approx. 20cm long in young adult males)
o Generally measured to the xiphoid
o Used for severe intra-abdominal or retroperitoneal hemorrhage
· Zone II: extends from the coeliac artery to the most caudal renal artery (approx. 3cm long)
· Zone III: extends distally from the most caudal renal artery to the aortic bifurcation (approx. 10cm long)
o Generally measured to just above the umbilicus
o Used for isolated pelvic, junctional or proximal lower extremity hemorrhage not amenable to tourniquet use
Indications for REBOA;
· PEA arrest < 10 mins of down time secondary to exsanguination from sub-diaphragmatic hemorrhage and femoral vessels are immediately identifiable on US
· Severe hypovolemic shock with SBP <70mmHg
· Patients in agonal state due to non-compressible exsanguinating hemorrhage who are non or partially responsive to rapid volume resuscitation
o Suspected or diagnosed intra-abdominal hemorrhage due to blunt trauma or penetrating torso injuries
o Blunt trauma with suspected pelvic fracture and isolated pelvic hemorrhage (zone III)
o Penetrating injury to the pelvic or groin area with uncontrolled hemorrhage
Contraindications for REBOA:
· Age > 70
· PEA arrest > 10 minutes
· Cardiac arrest due to causes other than exsanguination
· High clinical or radiological suspicion of proximal traumatic aortic dissection
· Pre-existing terminal illness or significant comorbidities
Steps:
1. Identify the CFA
2. Scrub, drape, prepare sheath
3. Place a femoral a-line
4. Insert short guidewire into femoral arterial line
5. Sequential dilation
6. Insert the 12F sheath
7. Insert long guide wire to mark
a. Zone 1: Xiphoid (approx. 50cm, T4-L1 mark)
b. Zone III: Umbilicus (appox 40cm, L2 to L4 mark)
8. Insert catheter to mark
9. Inflate balloon until moderate resistance is felt
a. Zone I: about 20 to 25mL
b. Zone III about 15 to 20mL
10. Confirm placement with x-ray
Target goal to release the tamponade from the REBOA would be 30mins but no greater than 50 mins.
Complications:
· Tissue ischemia may result from REBOA
· Reperfusion injury may occur
· Mechanical complications can occur from femoral artery access as well as injuries to the aorta and iliac artery
o Arterial disruption, Dissection, Pseudoaneurysms, hematoma
· Overinflating the balloon can result in balloon rupture or aortic injury
Controversies:
· High quality evidence for efficacy of REBOA is currently lacking
· Talks of weather REBOA is better suited for the prehospital setting or remote areas lacking immediate access to definitive surgical therapy
o This would be for example in community hospitals where EM physicians can place them and arrange for transfer to a facility that has surgical interventions available.
· EM physicians with advanced critical care training and proper credinataling can place a REBOA
References:
· https://litfl.com/reboa-in-resuscitation/
· https://rebelem.com/reboa-time/
· https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802990/
· https://tsaco.bmj.com/content/3/1/e000154