57: The New REBOA catheter – Perfecting the Partial Occlusion

Over the last several years, data has suggested that partial or intermittent REBOA may have benefit over complete REBOA.  How to do this and how to use our current imperfect catheters in this arena is still in question.  Dr. Matthew Martin and his colleagues at Madigan Medical Center have published the first study using Prytime's new catheter for partial REBOA.  Zack interviews Matt in this episode about this latest paper in Journal of Trauma and Acute Surgery as well as several other papers he's published in the field.  Dr. Martin is extensively published in the field and offers his insight in the specific flows that maximize survival within the conflicting problems of hemorrhagic shock and lower body ischemia.

 

 

 

 

Efficacy of intermittent versus standard resuscitative endovascular balloon occlusion of the aorta in a lethal solid organ injury model.

Kuckelman J, Derickson M, Barron M, Phillips CJ, Moe D, Levine T, Kononchik JP, Marko ST, Eckert M, Martin MJ.

J Trauma Acute Care Surg. 2019 Jul;87(1):9-17. doi: 10.1097/TA.0000000000002307.

PMID: 31259868

TITRATE TO EQUILIBRATE AND NOT EXSANGUINATE!: CHARACTERIZATION AND VALIDATION OF A NOVEL PARTIAL RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA CATHETER IN NORMAL AND HEMORRHAGIC SHOCK CONDITIONS.

Forte D, Do WS, Weiss JB, Sheldon RR, Kuckelman JP, Eckert MJ, Martin MJ.

J Trauma Acute Care Surg. 2019 May 21. doi: 10.1097/TA.0000000000002378. [Epub ahead of print]

PMID: 31135770

Resuscitative endovascular balloon occlusion of the aorta induced myocardial injury is mitigated by endovascular variable aortic control.

Beyer CA, Hoareau GL, Tibbits EM, Davidson AJ, DeSoucy ED, Simon MA, Grayson JK, Neff LP, Williams TK, Johnson MA.

J Trauma Acute Care Surg. 2019 Sep;87(3):590-598. doi: 10.1097/TA.0000000000002363.

PMID: 311453810

Selective Aortic Arch Perfusion with fresh whole blood or HBOC-201 reverses hemorrhage-induced traumatic cardiac arrest in a lethal model of non-compressible torso hemorrhage.

Hoops HE, Manning JE, Graham TL, McCully BH, McCurdy SL, Ross JD.

J Trauma Acute Care Surg. 2019 Apr 18. doi: 10.1097/TA.0000000000002315. [Epub ahead of print]

PMID:  31211744

49 – You Can’t Spell REBOA without the ER – Endovascular Resuscitation of the Trauma Patient – Zaf Qasim

In this episode, Zack Shinar interviews Zaf Qasim about the recent controversies with ACEP and ACS about who can do REBOA.  Zaf is one of the world's experts on REBOA and he's an ER doc!  Zaf works at the University of Pennsylvania, trained in London

as well as Shock Trauma in Baltimore and teaches at Reanimate.  When you come to the essence of this episode, the question is what is the emergency physician's role in the trauma resuscitation?  Both Zaf and Zack agree; we need to be the resuscitationist in the trauma suite.  We need to manage the airway and then quickly take over the arterial and venous access, interpret the transduced pressures, manage the massive transfusion protocol and be ready to insert the REBOA catheter while the trauma surgeon is involved with the left chest, the source of bleeding and where the next destination for this patient will be.

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 4

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]