Resuscitative Endovascular Balloon Occlusion of Aorta- is a new procedure being introduced in trauma centres. It is a procedure that has to be used for specific patients who have bleeding in the Abdomen or Pelvis , and there is a trauma surgeon on standby to perform the definitive surgery to close the bleeding wound in the abdomen/pelvis.
So this is a temporary measure, which can be done in the Emergency Dept or in the prehospital environment.
Simply put, it involves occlusion of the Aorta in Zone 1 or Zone 3 , using a Balloon catheter to buy time till the patient reaches the theatre.
The Catheter is inserted via the right femoral artery, Ultrasound guided and Seldinger Technique with all aseptic precautions.
So how do we select a patient for this procedure. There should be a trauma involving the trunk- blunt or penetrating. And the Blood pressure is not holding inspire of TXA and 1 bolus of fluid[ controversial] , if the BP temporarily holds at 90mm Systolic and starts dropping.
Once the need is established we have to rule out the contraindication- any injury to the arch of the Aorta and immediate descending aorta. This is done by performing an urgent CXR and we check for widening of the mediastinum.
Then a FAST Ultrasound scan is performed- if free fluid is noted on the scan- then it is assumed that one of the solid organs or the intestines are involved and the balloon is inflated in Zone 1- which is the part of the Aorta just above the Diaphragm or at least 1 cm above the origin of the coeliac artery.
This stops the blood supply to all the organs under the diaphragm and both the lower limbs- which means we are inducing 2 acutely ishaemic limbs and ischemic intestines and the largest internal organ- Liver and both Kidneys-
So zone 1 occlusion the holding time is 30 minutes to the surgeon closing the bleeding points in the upper abdomen.
This can be done in a setting where there is a Hybrid theatre fully prepared and waiting for a trauma patient.
With the recent spate of knife crimes in UK.. we should be introducing this technology in all major Trauma centres…to save those very young lives.
If the FAST scan is negative it means the bleeding is either retroperitoneal or in the pelvis- for which the balloon is inflated in the zone 3- just above the bifurcation.
The treatment here would be managing the pelvic injuries- again by embolisation of the pelvic vessels by an interventional radiologist.
The patient will have a rush of high K+ containing blood from the occluded organs and muscles once the balloon is deflated and the anaesthesiologist will need to know the point when the ballon is deflated- so that he is ready to manage any arrhythmias and low BP.
The patient will of course be transferred to ITU post op .