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American College of Surgeons issues position statement on use of REBOA on civilian trauma patients.

Sep 22, 2019

[From BMJ Journals]

Resuscitative endovascular balloon occlusion of the aorta (REBOA) was developed to address the challenge of managing non-compressible torso hemorrhage, a major cause of potentially preventable death after traumatic injury.1 Although balloon occlusion of the aorta has been used extensively in vascular surgery, its use in trauma was first described by a military surgeon as an attempt for hemorrhage control in three injured patients during the Korean War.2 Resurgence of the concept of REBOA along with recent evolution of the technology, which enhances the feasibility of REBOA, has led to increased interest in this approach as a bridge to hemorrhage control for critically injured patients. REBOA is also being explored for other indications, such as management of postpartum hemorrhage and use in medical cardiac arrest.

REBOA is not without significant risk. Occlusion of the aorta results in tissue ischemia followed by reperfusion injury, predisposing to organ dysfunction and cardiovascular collapse. In addition, several technical complications have been reported which impact lower limb perfusion. As a result, appropriate patient selection is critical to balancing the potential risks and benefits of REBOA use. Given the time-sensitive nature of this intervention, the system of care that surrounds this procedure is vital to minimizing delays to definitive hemorrhage control as well as the ischemic insult of aortic occlusion.

In 2018, the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) issued a joint statement on the clinical use of REBOA to address patient safety with the swift adoption of this technology.3 Due to the rapid evolution of this field and emerging clinical data, we committed to periodic re-evaluation and update of this statement. Consistent with this goal, a multidisciplinary, expert panel was convened to review the current literature and make recommendations in this regard. In addition to the original organizations, representatives from the National Association of EMS Physicians (NAEMSP) and the National Association of Emergency Medical Technicians (NAEMT) were invited to help address issues related to the proposed use of REBOA in the prehospital and interfacility transport environments.

This document focuses on the use of REBOA in civilian trauma patients and integration within civilian trauma systems in the USA. Our emphasis is on patient safety as the most important principle while recognizing the variability in trauma systems, trauma centers, and provider training across the USA. This document does not make recommendations regarding the US military’s use of REBOA, which is governed by the Joint Trauma System (JTS), the Department of Defense reference body for trauma care. This document also does not address potential indications for REBOA other than the management of patients with traumatic hemorrhage.

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