Pre-hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for exsanguinating pelvic haemorrhage

Robbie Lendrum; Zane Perkins; Manik Chana; Max Marsden; Ross Davenport; Gareth Grier; Samy Sadek; Gareth Davies

doi:10.1016/j.resuscitation.2018.12.018

Pre-hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for exsanguinating pelvic haemorrhage

Resuscitation. 2019 Feb:135:6-13. doi: 10.1016/j.resuscitation.2018.12.018. Epub 2018 Dec 27.

Authors

Robbie Lendrum¹, Zane Perkins², Manik Chana³, Max Marsden⁴, Ross Davenport⁵, Gareth Grier⁶, Samy Sadek⁷, Gareth Davies²

Affiliations

¹ Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; NHS Lothian, Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, United Kingdom. Electronic address: r.lendrum@nhs.net.
² Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; Centre for Trauma Sciences, Queen Mary University of London, Research Office Ward 12D, 12th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom.
³ The Institute of Pre-Hospital Care at London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom.
⁴ Centre for Trauma Sciences, Queen Mary University of London, Research Office Ward 12D, 12th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom.
⁵ Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; Centre for Trauma Sciences, Queen Mary University of London, Research Office Ward 12D, 12th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom.
⁶ Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; The Institute of Pre-Hospital Care at London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom.
⁷ Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom.

PMID: 30594600
DOI: 10.1016/j.resuscitation.2018.12.018

Abstract

Aim: To report the initial experience and outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an adjunct to pre-hospital resuscitation of patients with exsanguinating pelvic haemorrhage.

Methods: Descriptive case series of consecutive adult patients, treated with pre-hospital Zone III REBOA by a physician-led pre-hospital trauma service, between January 2014 and July 2018.

Results: REBOA was attempted in 19 trauma patients (13 successful, six failed attempts) and two non-trauma patients (both successful) with exsanguinating pelvic haemorrhage. Trauma patients were severely injured (median ISS 34, IQR: 27-43) and profoundly hypotensive (median systolic blood pressure [SBP] 57, IQR: 40-68 mmHg). REBOA significantly improved blood pressure (Pre-REBOA median SBP 57, IQR: 35-67 mmHg versus Post- REBOA SBP 114, IQR: 86-132 mmHg; Median of differences 66, 95% CI: 25-74 mmHg; P < 0.001). REBOA was associated with significantly lower risk of pre-hospital cardiac arrest (REBOA 0/13 [0%] versus no REBOA 3/6 [50%], P = 0.021) and death from exsanguination (REBOA 0/13 [0%] versus no REBOA 4/6 [67%], P = 0.004), when compared to patients with a failed attempt. Successful REBOA was associated with improved survival (REBOA 8/13 [62%] versus no REBOA 2/6 [33%]; P = 0.350). Distal arterial thrombus requiring thrombectomy was common in the REBOA group (10/13, 77%).

Conclusion: REBOA is a feasible pre-hospital resuscitation strategy for patients with exsanguinating pelvic haemorrhage. REBOA significantly improves blood pressure and may reduce the risk of pre-hospital hypovolaemic cardiac arrest and early death due to exsanguination. Distal arterial thrombus formation is common, and should be actively managed.

Keywords: Exsanguinating haemorrhage; Exsanguination; Hypovolaemic cardiac arrest; Junctional haemorrhage; Non-compressible torso haemorrhage; Pelvic haemorrhage; REBOA; Resuscitative Endovascular Balloon Occlusion of the Aorta; Trauma haemorrhage; Trauma resuscitation.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Aorta / surgery
Balloon Occlusion* / adverse effects
Balloon Occlusion* / methods
Blood Vessel Prosthesis Implantation / adverse effects
Blood Vessel Prosthesis Implantation / methods
Emergency Medical Services / methods
Endovascular Procedures* / adverse effects
Endovascular Procedures* / methods
Exsanguination* / diagnosis
Exsanguination* / therapy
Feasibility Studies
Female
Humans
Male
Middle Aged
Out-of-Hospital Cardiac Arrest* / etiology
Out-of-Hospital Cardiac Arrest* / prevention & control
Outcome and Process Assessment, Health Care
Pelvis*
Resuscitation / methods
Retrospective Studies
Shock, Hemorrhagic* / etiology
Shock, Hemorrhagic* / prevention & control
Thrombosis / diagnosis
Thrombosis / etiology
Trauma Severity Indices
United Kingdom