Another situation not discussed in the TCCC Guidelines that you may encounter as CPP-level providers is non-compressible torso hemorrhage (NCTH). This can be defined as high-grade injury present in one or more of the following anatomic domains: pulmonary, solid abdominal organ, major vascular or pelvic trauma; plus, hemodynamic instability or the need for immediate hemorrhage control.43 In these situations, the standard interventions for massive hemorrhage and circulation control that have been discussed do not have appreciable impact.44

NCTH may cause shock and death despite relatively unimpressive entrance wounds. Currently, the mainstays of treatment include administration of tranexamic acid (discussed in the next module), resuscitation with whole blood (which replaces losses, but does not affect ongoing continued losses), and rapid transportation to a facility where definitive surgical control of the hemorrhage can be achieved. Transport of a casualty with suspected NCTH should be accomplished on an emergent basis.45

Two newer technologies that may assist with NCTH control are Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and ResQFoam™, an intraperitoneally injected polyurethane self-expanding foam.46

REBOA hemorrhage control is a developing field with new information being published continuously, so the intent of this discussion is to introduce the concept, and understand its indications and limitations. For a more complete understanding of REBOA, refer to the JTS clinical practice guideline Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Hemorrhagic Shock (CPG ID:38).47,48 REBOA can control NCTH using a less invasive option and with fewer physiologic disturbances compared with an invasive emergent thoracotomy for aortic cross-clamping.49

REBOA devices are inserted via the femoral artery, and consist of a catheter with an inflatable balloon. The catheter is passed retrograde up to the desired site of occlusion, and the balloon is inflated, stopping distal flow below the site of occlusion.50, 51 Traditionally, the procedure has been done mostly in medical treatment facilities under fluoroscopic guidance. But there have been use cases in more austere environments.52, 53, 54