ER-REBOA Patient Selection, the Procedure, and Outcomes Joseph Ibrahim, MD FACS Trauma Medical Director Orlando Regional Medical Center
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1 ER-REBOA Patient Selection, the Procedure, and Outcomes Joseph Ibrahim, MD FACS Trauma Medical Director Orlando Regional Medical Center Disclosures Speaking Consultant with Prytime Medical Outline Mechanism of Injury I. Indications II. Contraindications III. Procedure IV. Trouble Shooting V. Post Occlusion Management VI. Pitfalls Mechanism of Injury History We re # 1 1
2 History 1954 Lieutenant Colonel Carl W. Hughes 10 fr. Catheter with 20 cc balloon Arbitrarily utilized after 10 units of blood if no bp obtained Attempted in three patients History History History 1976 Ann Ledgerwood Journal of Trauma The Role of Thoracic Aortic Occlusion for Massive Hemoperitoneum 40 patients: 11-immediate laparotomy; 29 thoracotomy then laparotomy Six of the first group survived secondary to thoracotomy while 22 of the 29 showed bp improvement Conclusion.The Role of Thoracic Aortic Occlusion for Massive Hemoperitoneum. Ledgerwood AM, Kazmers M, Lucas CE. J Trauma Aug;16(08): History Thoracotomy results 4-33% survival 18-33% in penetrating trauma 2000 Rhee 24 studies involving 4600 patients over the last 25 yrs 7.4% survival rate overall History History Gupta, consecutive patients with penetrating abdominal trauma treated with intra-aortic balloon occlusion 3 groups evaluated: no bp, bp < 80 torr systolic, bp < 80 torr during prep for laparotomy Results: no survivors in group 1, 3 of 6 in group two, and 4 of 10 in group three 2
3 Indications Indications J Trauma Acute Care Surg.2015 May;78(5): doi: The role of REBOA in the control of exsanguinating torso hemorrhage. Biffl WL, Fox CJ, Moore FF. Indications (Shock Trauma Algorithm) Indications SBP <90 mmhg Presence of trauma with concern for abdominal, pelvic, or lower extremity hemorrhage Absence of widened mediastinum on cxr If these criteria are met, proceeds at the very least with obtaining access Indications Access 7 fr sheath in the CFA U/S guidance recommended No catheters in SFA Placement needs to be within 2 inches of the inguinal ligament to avoid going to low Contraindications Widened Mediastinum Impact on thoracic aorta trauma is unknown 3
4 Hemorrhage Control Hemorrhage Control Procedure Measure, Mark, Insert Initially only a 12 fr sheath was used followed by placement of a large balloon catheter requiring arterial repair afterwards Insert 7 fr sheath into the femoral artery within 2 cm of the inguinal ligament (u/s guidance is recommended) Determine appropriate zone Zone I is at or above the diaphragm Used in event of positive FAST P at the sternal notch Zone III is at the level of the umbilicus Used with negative FAST and presence of pelvic fracture P at the xiphoid process Procedure Inflation volume: 5 or 8 - don t overinflate (5 or 8 cc s) Zone 1 insertion depth = 46 cm Zone 3 insertion depth = 27 cm 4
5 Procedure This 6 steps of REBOA are ME-FIIS pronounced ME-FIZZ Measure measure distance Evacuate evacuate the balloon Flush flush the arterial line Insert insert the catheter Inflate inflate the balloon Secure secure the catheter Procedure Flush arterial line port with saline Ensure proper wave form upon insertion of catheter Insert to desired measurement dependent on desired zone Check position with portable x-ray Slowly inflate balloon until see a rise in bp then stop immediately 5 cc s in zone III 8 cc s in zone I Secure catheter in position Catheter fastener Suture Ioban Kerlex Mobilize to OR or IR Pitfalls Conclusions Do not leave inflated > 30 min Do not expect tactile sensation for balloon filling Catheter should slide easily, if any resistance, could be creating a dissection Avoid in patients with a widened mediastinum REBOA is a safe and effective tool when used correctly for the correct indications Utilizing algorithms and protocols will help identify those most likely to benefit Do not place in patients with a widened mediastinum Do not leave inflated for > 30 minutes Flush arterial line prior to use Do not force if it does not go easily Safe implementation of a REBOA program should be well thought out and involve multiple departments ER-REBOA CASE REVIEWS Joseph Ibrahim, MD FACS Trauma Medical Director Orlando Regional Medical Center CASE 1 52 yof s/p auto vs pedestrian hypotensive at the scene with gcs of 9 at the scene improved to 14 at the scene with bp 110/65 on arrival 5
6 CASE 1 CASE 1 CASE 1 CASE 1 CASE 1 CASE 1 After returning from CT bp drops to 70/40 Next Steps: Transfuse? 6
7 CASE 1 CASE 1 Negative A-gram REBOA and sheath removed CASE 1 CASE 2 26 yo female presents as pedestrian vs. MVC. Intubated upon arrival. Pressure 53/30 on arrival. GCS 7. CASE 2 CASE 2 7
8 CASE 2 CASE 2 Positive FAST Next Steps Transfuse? TXA? ICU? CASE 2 REBOA placed at zone 1 Ex lap=large nonexpanding rp hematoma stable, abthera REBOA withdrawn A-gram neg via same sheath(intraop) Abd larger-blood under abthera Next step? CASE 2 Replaced REBOA enlarging rp hematoma medial visceral rotation of rt colon, right nephrectomy performed REBOA removed CASE 3 CASE 3 34 y/o M trauma alert s/p high-speed MVC. Pt was restrained driver, ran into a metal telephone pole; extensive vehicle damage; + LOC; b/l leg entrapment needing extrication. On arrival, pt was in moderate respiratory distress, hypotensive and tachycardic, GCS14. Pt complaining of severe dyspnea, LLE and LUE pain; worsened with movement and palpation; improved with narcotics. Pt's mental status was beginning to decline and was in respiratory failure, pt was intubated without complications. 8
9 CASE 3 CASE 3 FAST Negative Next Steps? CT? CASE 3 CASE 3 Patient to OR EX-LAP Pre-Peritoneal Packing Repair of left hemidiaphragm CASE 4 CASE 4 73 y/o M presents to ORMC after MVC. Patient was driving and struck on driver side by another vehicle. He was HDS. Complaining of pain in left hip and left chest, 10/10, worse with movement, nonradiating and located on left chest, left lower extremity, and left abdomen. GCS of 15 on presentation. 9
10 CASE 4 CASE 4 Negative FAST Drops BP to 80/40 mmhg Next step? OR Binder IR REBOA Stabilizes with one unit of PRBC s Contraindication for REBOA Thoracic Aorta Injury Left acetabulum fx To ICU BP control Ortho consultation CASE 4 CASE 5 26 F who presents to ORMC ED as trauma alert restrained driver s/p MVC vs pole, with heavy entrapment for 30 mins. Became hypotensive; she was agitated for EMS w/ a GCS of 4 on arrival to TB. She was tachycardic to 140s. CASE 5 CASE 5 10
11 CASE 5 CASE 5 FAST Positive Next Steps TXA? MTP? CASE 6 CASE 6 34 y/o F presents to ORMC as a trauma alert s/p falling off the back of a motor cycle. +LOC. Per EMS, pt was GCS 15 and HDS on scene and en route; they placed a traction splint on her LLE due to an obvious Left femur deformity. On presentation to the trauma bay, pt was HDS with a GCS of 15 complaining of LLE pain. CASE 6 CASE 6 11
12 CASE 6 CASE 6 Case 6 CASE 6 Patient became hypotensive and unresponsive to IVF, 2 units of emergency release given with transient response Negative FAST Next Steps ZONE? CASE 7 CASE 7 46F restrained driver s/p driver's side T-bone MVC with airbag deployment. Per ED resident patient arrived GCS 14, tachycardic, tachypneic, and diaphoretic with a seatbelt sign. 12
13 CASE 7 CASE 7 FAST NEGATIVE NEXT STEP? CASE 8 CASE 8 Unknown age male trauma alert s/p pedestrian vs auto at high rate of speed. Patient brought in GCS 3 PEA. ACLS was initiated. The patient was a difficult intubation. He was successfully intubated with the glide-e-scope. The patient received ROSC. He has obvious trauma to the head, chest, and all 4 extremities. Bilateral chest tubes were placed. A central line and a-line were placed. MTP initiated CASE 8 CASE 8 FAST Positive Hypotensive with BP 60/40 mmhg Next step? EX LAP Pre-Peritoneal Packing Thoracotomy? 13
14 CASE 9 61 yom trauma alert arrived to ORMC after being struck by a car at 40mph. The patient was confused on scene. He was less confused on arrival to ORMC answering basic questions about his name, birthdate, and medical history. He was given two liters of NS and then two units of blood but remained persistently hypotensive. CASE 9 CASE 9 CASE 9 FAST Positive Next Step ICU? Arrests in OR ROSC after brief period of CPR Next step Aorta Cross Clamp Laparotomy? CASE 9 CASE y/o F trauma alert transfer after moped vs bus earlier this morning. Coded in field/at outside facility with ROSC. Intubated and transferred to ORMC for further management. On arrival, bilateral chest tubes placed, and central venous access obtained. Became hypotensive, requiring blood transfusions and vasopressors. 14
15 CASE 10 CASE 10 Positive FAST Plan? ICU? Cross Clamp? ZONE? CASE 11 CASE yof presents to ORMC as a Trauma alert s/p MCC. Patient arrived and was agitated, and anxious. Initial evaluation revealed that the patient had an open book pelvic, and a vaginal laceration. The patient then became hypotensive and HD unstable. The patient then underwent RSI for air way protection. A right subclavian CVC and a left femoral A Line were emergently placed. CASE 11 CASE 11 FAST Negative Next Step Preperitoneal Packing? 15
16 CASE 11 CASE yom restrained driver in HOC with brief LOC, HD stable initially but dropped to 80/45 mm Hg and open femur fracture Intermittently responsive to fluid boluses CASE 12 CASE 12 CASE 12 NONTRAUMA CASES Negative FAST Next Step? PRBC? Ex Laparotomy? Complicated Placental Issues Accreta Increta 3 Cases 2 after MTP initiated 1 with cardiac arrest during procedure 1 prophylactic placement after c-section 100 cc ebl No transfusions D/C d Post op day 2 Now incorporated into institutional protocol 16
17 NONTRAUMA CASES 50 s yom 3 weeks s/p whipple Presents with hypotension, tachycardia ER-REBOA placed in zone I SMA bleed Pt stabilized and repaired Currently on medsurg floor ER REBOA is not the Holy Grail Conclusions It is a helpful tool for hemorrhage control and improvement in bp Recognizing the indications, contraindications, and proper planning for implementation are paramount to its success Its benefits may be far reaching well beyond the world of trauma as we continue to look at potential uses. Thank You 17
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