70: REBOA REDUX – Management of Hemorrhagic Shock in Non-Trauma Patients – with Bellezzo & Zaf Qasim

January 1, 2021: The year following COVID19 Global Pandemic brings us a new horizon – lets appreciate what has happened, learn from our mistakes and begin to look forward.

 

In this episode Joe Bellezzo talks with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) expert Dr. Zaf Qasim about NON-TRAUMA applications of aortic compression for control of non-compressible non-trauma torso hemorrhage.

 

 

Dr. Qasim is a world expert in REBOA and has been on the podcast:

edecmo.org/35 – REBOA revisited

edecmo.org/49 – the ACEP-ACS joint statement controversy

edecmo.org/59 – Partial REBOA

 

REBOA in Hemorrhagic Shock from NON-Trauma Mechanisms:

This episode is highlighted by a remarkable case, managed by Emergency Physician Dr. Garrett Sterling, of a 77 year old patient who suffered non-traumatic hemorrhagic shock from an Iliac artery pseudo-aneurysm that had fistulized to the urinary tract.  The patient was bleeding to death from a fistula between the common iliac artery and the ureter. You have to listen to Dr. Sterling describe this case. The patient was resuscitated with REBOA and her pathology was fixed by an Iliac Artery stent placed in Interventional Radiology. We discuss this case which highlights the benefit of REBOA as a bridge to definitive hemorrhage control.

Amazing patient who had an Iliac pseudo-aneurysm causing hemorrhagic shock through the urinary tract, resuscitated using REBOA.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Joe and Zaf talk about:

  1. brief history of managing hemorrhagic shock with aortic occlusion
  2. ‘Knee REBOA'
  3. Resuscitative thoracotomy
  4. REBOA in trauma
  5. REBOA in non-trauma hemorrhagic shock

 

REFERENCES:

https://pubmed.ncbi.nlm.nih.gov/29922894/

https://pubmed.ncbi.nlm.nih.gov/31799415/

https://pubmed.ncbi.nlm.nih.gov/32707397/

https://pubmed.ncbi.nlm.nih.gov/31668242/

https://tsaco.bmj.com/content/4/1/e000376

https://pubmed.ncbi.nlm.nih.gov/29421694/

Click to access 20202110O'Dochartaigh.pdf

 

 

 

 

EDECMO 35 – REBOA REVISITED!

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is used to gain proximal control over non-compressible hemorrhage below the diaphragm.  The concept has been covered extensively in social media.

Weingart did a wonderful job describing REBOA using the 12F Chek-Flo and CODA catheter here:

EMCrit Podcast 121 – REBOA

Our good friend Rob Orman from ERCAST.org and EMRAP interviewed Zaf Qasim:

REBOA 101

And Weingart revisited REBOA, spoke with Joe DuBose, and described the newest REBOA catheter, the PryTime 7F ER REBOA catheter that most of us now use:

Podcast 170 – the ER REBOA Catheter with Joe DuBose

 

…So we aren't going to rehash any of that stuff in this episode!

In this episode, Zack takes a deep dive into REBOA implementation, physiology, and complications with four of the biggest movers in the world of REBOA:

Dr. David Callaway Military Trauma Specialist

Dr. David Callaway is an Emergency Physician from the Carolinas Health System, who also serves on the Defense Health Board Subcommittee on Trauma and Injury as well as the Committee on Tactical Combat Casualty Care- two of the key U.S. advisory bodies for battlefield trauma care.

He is the Co- Chairman of the Committee for Tactical Emergency Casualty Care, a best practices R&D group charged with translating battlefield lessons learned to civilian high threat prehospital medicine.

Dr. Callaway describes how they implement REBOA  in their busy trauma unit and some of the data behind its use.


 

Dr. Tatuya Norii University of New Mexico

But REBOA is not without controversy.  So Zack turned to Dr. Tatsuyo Norii, from the University of New Mexico, who published a study that showed that REBOA may result in increased mortality in certain patients.1 Dr. Norii believes that we should avoid REBOA in patients with traumatic brain injury and patients with multi-system trauma.

Shinar and Dr. Norii also discussed how REBOA may also be considered  non-trauma situations where patients are bleeding to death:  ruptured ectopic pregnancy, postpartum hemorrhage, ruptured abdominal aneurysm, and perhaps some patients with hemorrhagic gastrointestinal bleeding.

 


Austin Johnson MD PhD UC Davis

Then,  Zack turned to Dr. Austin Johnson from UC Davis.  They do  a deep dive into the physiology of of a patient on REBOA and its nuances in traumatic brain injury.

And lastly, They discussed the concept of partial REBOA (P-REBOA) and the concept of “windsocking”. As the balloon size is decreased by decreasing the volumes within it, the flow around the balloon is not linear. This becomes increasingly important as we consider ‘partial REBOA', prolonged occlusion, and balloon takedown, a topic published by Dr. Johnson a few months ago.2

 


Zaf Qasim MD REBOA guru

Finally, we wrap things up with a discussion with Zaf Qasim, REBOA guru who teaches the REBOA modules at our endovascular resuscitation conference, REANIMATE.

Do you want to learn how to aggressively manage the crashing trauma and medical patients using ECMO, ECPR, REBOA, ultrasound  and advanced resuscitation techniques?

 

REANIMATE 4 is September 21-22, 2017:

Register for REANIMATE 8

References

1.
Norii T, Crandall C, Terasaka Y. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg. 2015;78(4):721-728. [PubMed]
2.
Johnson M, Neff L, Williams T, DuBose J, EVAC S. Partial resuscitative balloon occlusion of the aorta (P-REBOA): Clinical technique and rationale. J Trauma Acute Care Surg. 2016;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S133-S137. [PubMed]