Background

- Hemorrhage continues to be a leading cause of preventable death on the battlefield. It can be broadly categorized as compressible or non-compressible depending on its location. Non-Compressible Torso Hemorrhage (NCTH) arises from trauma to the torso vessels, pulmonary parenchyma, solid abdominal organs, or the bony pelvis.1 Because NCTH is not amenable to control by direct pressure or extremity tourniquet application, it is particularly lethal.2
- Resuscitative Aortic Occlusion (RAO) affords distal hemorrhage control while increasing cardiac afterload and thereby maintaining coronary and cerebral perfusion pressure until direct hemostasis can be achieved.3 RAO has traditionally required a left thoracotomy or laparotomy for aortic exposure.4-7 Resuscitative thoracotomy has a high mortality rate, due largely to the nature of the injuries leading to arrest.8-10 Nonetheless, data from combat theaters indicate that there is a reasonable probability of long-term survival and recovery following RAO in appropriately selected casualties as described in the JTS Emergent Resuscitative Thoracotomy (ERT) CPG.11-13
- There is no high grade evidence defining the specific indications for REBOA, nor that REBOA improves survival or outcomes as compared to ERT.14 There is literature demonstrating both a survival benefit with REBOA 15-16 as well as data suggesting that REBOA may actually worsen mortality.17-18 The advent of the wireless ER-REBOA and a better understanding of REBOA indications has led to recent studies demonstrating the non-inferiority of REBOA. In patients that do not require CPR, REBOA has now shown a survival benefit.19-23 In the highest quality prospective analysis available, REBOA improved survival beyond the emergency department and to hospital discharge compared to ERT when applied prior to traumatic cardiac arrest in patients with hemorrhagic shock.23
- REBOA is an alternative form of RAO for patients at risk of imminent cardiovascular collapse. It is performed through a femoral artery approach without the need for thoracotomy. REBOA is best applied prior to cardiovascular collapse when the site of hemorrhage is below the diaphragm and no open thoracic intervention is otherwise indicated.23
- ERT allows management of thoracic injuries and manual cardiac compression and thus remains the procedure of choice for patients with significant thoracic or cardiac injury. REBOA has been used in combination with open thoracotomy and/or sternotomy as a resuscitative bridge to open surgical control of hemorrhage to treat thoracic great vessel injury.24