The Changing Landscape of Trauma Care, Part 2
Once inflated, the balloon obstructs arterial inflow to the area of hemorrhage, curtailing blood loss, and increases proximal BP, improving coronary and cerebral perfusion. Multiple case reports and case series have described successful use of REBOA for hemorrhage control, including prehospital use by physicians in the United Kingdom. The largest series to date looked at 114 patients, of whom 46 had REBOA placement and 68 had open aortic occlusion through resuscitative thoracotomy.45 Those treated with REBOA were significantly more likely to achieve hemodynamic stability (defined as SBP >90 mm Hg for >5 minutes). Furthermore, the authors noted minimal complications from REBOA and no difference in time to successful aortic occlusion, regardless of technique. There was also no difference in mortality between the two groups. Despite the small number of studies in trauma patients, REBOA has been established as a viable alternative to open aortic occlusion. The prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry established by the American Association for the Surgery of Trauma is continuing to enroll patients and will hopefully answer many of the current uncertainties regarding the use of REBOA.
Conclusion
Strategies and techniques for the care of the injured patient have changed significantly in the past few years. Damage control resuscitation includes three elements: damage control surgery, permissive hypotension, and blood-product resuscitation.
The goals of lowering MAP in hemorrhagic shock appear to be safe and make sense physiologically, but have yet to show clear mortality benefit. Avoidance of excessive crystalloid resuscitation and trends toward more physiological ratios of blood product resuscitation have shown better outcomes. While the ideal ratio of blood products in transfusion remains unknown, the use of a massive transfusion strategy is preferable to crystalloid fluids. The use of viscoelastic assays (TEG and ROTEM) have allowed for goal-directed blood product resuscitation and may improve outcomes when compared with prescribed resuscitation ratios.
Finally, endovascular techniques in trauma have been increasingly utilized over the past 15 years, making nonoperative management with angiographic embolization for solid organ injury common practice now in most trauma centers worldwide. Temporary aortic balloon occlusion with REBOA appears promising in many cases of noncompressible truncal hemorrhage until definitive hemostasis can be achieved, but studies are needed to determine its ultimate place in the care of the trauma patient.
