II. Indications
- Noncompressible, subdiaphragmatic Hemorrhage in the Abdomen or Pelvis
- Consider in severe Hemorrhagic Shock before Cardiac Arrest
- Does not replace Resuscitative Thoracotomy
- REBOA is an adjunct that reduces subdiaphragmatic Hemorrhage
- Chest Hemorrhage is a relative contraindication to REBOA as it would likely increase chest bleeding
- Severe Pelvic Fractures who have not had Cardiac Arrest who need immediate temporizing measures
- May be considered in Peri-Arrest patient without obvious source of Hemorrhage
- Best used for short-term bridging to definitive procedure (risk of distal ischemia)
III. Contraindications (Cases in Which Emergency Thoracotomy are instead indicated)
- Penetrating Chest Trauma
- Uncontrolled chest Hemorrhage
- Cardiac Tamponade
- Previous vascular surgery
- Suspected aortic injury
IV. Technique
- Performed in 5-10 minutes in skilled hands
- Catheter insertion length determined prior to insertion (mark stop point)
- Common femoral artery cannulated
- Traditionally performed via very large bore catheters (12-14F)
- Newer commercial kits use arterial catheters smaller than 14F
- Typically placed under Bedside Ultrasound guidance
- Percutaneous balloon delivered via femoral artery catheter and inflated in aorta above level of suspected Hemorrhage
- Avoid catheter placement in Zone 2 (between Celiac Artery and renal arteries)
- Zone 1: Subdiaphragmatic (typical target for balloon placement), but above Celiac Artery
- Indicated for intra-abdominal bleeding (e.g. positive FAST Scan) to reduce splanchnic flow
- Zone 3: Between renal arteries and iliac Bifurcation
- Indicated for pelvic source of bleeding
- Percutaneous balloon inflation
- Arterial waveform monitored during balloon passage and inflation
- Inflate the percutaneous balloon until target
- Systolic Blood Pressure increases by 10 mmHg AND
- Pulse is not present in contralateral lower extremity
V. Efficacy
- Efficacy is difficult to measure for a last-ditch effort to stave off death for minutes to allow for emergent surgery
- Studies in 2016, suggest lower efficacy than initially thought, and may be associated with higher mortality
- Retrospective study showed reduced mortality in Hemorrhagic Shock with REBOA compared with Resuscitative Thoracotomy
- However, this was not a direct comparative trial and further studies are needed
- Cralley (2023) JAMA Surg 158(2):140-50 +PMID: 36542395 [PubMed]
VI. Complications
- Aortic Dissection, pseudoaneurysm (or other aortic injury)
- Suprarenal Occlusion (balloon too high, unless intended for zone 1)
- Internal organ and lower extremity ischemic injury
- Distal Thromboembolism
VII. Resources
- HQMedEd (Glenn Paetow)
VIII. References
- Inaba in Herbert (2013) EM:Rap 13(11): 3-4
- Shoenberger, Swadron and Inaba in Herbert (2018) 18(12): 10-11
- Ringhauser (2019) Crit Dec Emerg Med 33(6): 19-25
- Hughes (1954) Surgery 36(1):65-8 [PubMed]