Damage control resuscitation: REBOA as the new fourth pillar
Abstract
Damage Control Resuscitation (DCR) seeks to combat metabolic decompensation of the severely injured trauma patient by battling on three major fronts: Permissive Hypotension, Hemostatic Resuscitation, and Damage Control Surgery (DCS). The aim of this article is to perform a review of the history of DCR/DCS and to propose a new paradigm that has emerged from the recent advancements in endovascular technology: The Resuscitative Balloon Occlusion of the Aorta (REBOA). Thanks to the advances in technology, a bridge has been created between Pre-hospital Management and the Control of Bleeding described in Stage I of DCS which is the inclusion and placement of a REBOA. We have been able to show that REBOA is not only a tool that aids in the control of hemorrhage, it is also a vital tool in the hemodynamic resuscitation of a severely injured blunt and/or penetrating trauma patient. That is why we propose a new paradigm “The Fourth Pillar”: Permissive Hypotension, Hemostatic Resuscitation, Damage Control Surgery and REBOA.
Authors
Downloads
Keywords
- Damage Control Surgery
- Damage Control Resuscitation
- REBOA
- Trauma Centers
- Thrombelastography
- Advanced Trauma Life Support Care
- Tourniquets
- Triage
- Fibrinogen
- Hypothermia
- Intra-Abdominal Hypertension
References
Stone HH, Strom PR, Mullins RJ. Management of the Major Coagulopathy with Onset during Laparotomy. Ann Surg 1983;197:532-5. https://doi.org/10.1097/00000658-198305000-00005
Carmona RH, Lim RC, Lim RC. The role of packing and planned reoperation in severe hepatic trauma. J Trauma - Inj Infect Crit Care 1984;24:779-84. https://doi.org/10.1097/00005373-198409000-00001
Feliciano D V., Mattox KL, Burch JM, Bitondo CG, Jordan GL. Packing for control of hepatic hemorrhage. J Trauma - Inj Infect Crit Care 1986;26:738-43. https://doi.org/10.1097/00005373-198608000-00010
Krige JEJ, Bornman PC, Terblanche J. Therapeutic perihepatic packing in complex liver trauma. Br J Surg 1992;79:43-6. https://doi.org/10.1002/bjs.1800790114
Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin North Am 1997;77:761-77. https://doi.org/10.1016/S0039-6109(05)70582-X
Johnson JW, Gracias VH, Schwab CW, Reilly PM, Kauder DR, Shapiro MB, et al. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma 2001;51:261-71. https://doi.org/10.1097/00005373-200108000-00007
Ferrara A, MacArthur JD, Wright HK, Modlin IM, McMillen MA. Hypothermia and acidosis worsen coagulopathy in the patient requiring massive transfusion. Am J Surg 1990;160:515-8. https://doi.org/10.1016/S0002-9610(05)81018-9
Timmermans J, Nicol A, Kairinos N, Teijink J, Prins M, Navsaria P. Predicting mortality in damage control surgery for major abdominal trauma. S Afr J Surg 2010;48:6-9.
Beecher H. Preparation of battle casualties for Surgery. Ann Surg 1945;121:769-92. https://doi.org/10.1097/00000658-194506000-00001
Cannon E. Nature and treatment of wound shock and allied conditions. JAMA 1918;70:520. https://doi.org/10.1001/jama.1918.02600080022008
Holcomb JB, Jenkins D, Rhee P, Johannigman J, Mahoney P, Mehta S, et al. Damage control resuscitation: Directly addressing the early coagulopathy of trauma. J Trauma - Inj Infect Crit Care 2007;62:307-10. https://doi.org/10.1097/TA.0b013e3180324124
Bickell WH, Wall MJ, Pepe PE, Martin RR, Ginger VF, Allen MK, et al. Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. N Engl J Med 1994;331:1105-9. https://doi.org/10.1056/NEJM199410273311701
Fox CJ, Gillespie DL, Cox ED, Kragh JF, Mehta SG, Salinas J, et al. Damage control resuscitation for vascular surgery in a combat support hospital. J Trauma - Inj Infect Crit Care 2008;65:1-9. https://doi.org/10.1097/TA.0b013e318176c533.
Cannon JW, Khan MA, Raja AS, Cohen MJ, Como JJ, Cotton BA, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. J. Trauma Acute Care Surg., vol. 82, Lippincott Williams and Wilkins; 2017, p. 605-17. https://doi.org/10.1097/TA.0000000000001333
Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: The PROPPR randomized clinical trial. JAMA - J Am Med Assoc 2015;313:471-82. https://doi.org/10.1001/jama.2015.12
Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007;63:805-13. https://doi.org/10.1097/TA.0b013e3181271ba3
Sperry JL, Ochoa JB, Gunn SR, Alarcon LH, Minei JP, Cuschieri J, et al. An FFP:PRBC transfusion ratio >/=1:1.5 is associated with a lower risk of mortality after massive transfusion. J Trauma 2008;65:986-93. https://doi.org/10.1097/TA.0b013e3181878028
Rhee P, Koustova E, Alam HB. Searching for the optimal resuscitation method: Recommendations for the initial fluid resuscitation of combat casualties. J. Trauma - Inj. Infect. Crit. Care, vol. 54, Lippincott Williams and Wilkins; 2003, p. S52-62. https://doi.org/10.1097/01.TA.0000064507.80390.10
Holcomb JB. Transport time and preoperating room hemostatic interventions are important: Improving outcomes after severe truncal injury. Crit Care Med 2018;46:447-53. https://doi.org/10.1097/CCM.0000000000002915
Holcomb JB, Jenkins DH. Get ready: whole blood is back and it's good for patients. Transfusion 2018;58:1821-3. https://doi.org/10.1111/trf.14818
Pivalizza EG, Stephens CT, Sridhar S, Gumbert SD, Rossmann S, Bertholf MF, et al. Whole blood for resuscitation in adult civilian trauma in 2017: A narrative review. Anesth Analg 2018;127:157-62. https://doi.org/10.1213/ANE.0000000000003427
Giancarelli A, Birrer KL, Alban RF, Hobbs BP, Liu-Deryke X. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res 2016;202:182-7. https://doi.org/10.1016/j.jss.2015.12.036
Ditzel RM, Anderson JL, Eisenhart WJ, Rankin CJ, DeFeo DR, Oak S, et al. A review of transfusion- And trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg 2020;88:434-9. https://doi.org/10.1097/TA.0000000000002570
Asensio JA, Petrone P, Roldán G, Kuncir E, Ramicone E, Chan L. Has evolution in awareness of guidelines for institution of damage control improved outcome in the management of the posttraumatic open abdomen? Arch Surg 2004;139:209-14; discussion 215. https://doi.org/10.1001/archsurg.139.2.209
Arthurs Z, Kjorstad R, Mullenix P, Rush RM, Sebesta J, Beekley A. The use of damage-control principles for penetrating pelvic battlefield trauma. Am J Surg 2006;191:604-9. https://doi.org/10.1016/j.amjsurg.2006.02.009
Ferrada R, Birolini D. New concepts in the management of patients with penetrating abdominal wounds. Surg Clin North Am 1999;79:1331-56. https://doi.org/10.1016/s0039-6109(05)70081-5.
Hirshberg A, Mattox KL. Top Knife. 2011. https://doi.org/10.1007/978-88-470-1741-2.
Digiacomo JC, Rotondo MF, Schwab CW. Transcutaneous balloon catheter tamponade for definitive control of subclavian venous injuries. J Trauma - Inj Infect Crit Care 1994;37:111-3. https://doi.org/10.1097/00005373-199407000-00018
McAnena OJ, Moore EE, Moore FA. Insertion of a retrohepatic vena cava balloon shunt through the saphenofemoral junction. Am J Surg 1989;158:463-6. https://doi.org/10.1016/0002-9610(89)90288-2
Thomas S V., Dulchavsky SA, Diebel LN. Balloon tamponade for liver injuries: Case report. J Trauma - Inj Infect Crit Care 1993;34:448-9. https://doi.org/10.1097/00005373-199303000-00026
Sugrue M, Jones F, Janjua KJ, Deane SA, Bristow P, Hillman K. Temporary abdominal closure: a prospective evaluation of its effects on renal and respiratory physiology. J Trauma 1998;45:914-21. https://doi.org/10.1097/00005373-199811000-00013
Degiannis E, Levy RD, Velmahos GC, Mokoena T, Daponte A, Saadia R. Gunshot injuries of the liver: The Baragwanath experience. Surgery 1995;117:359-64. https://doi.org/10.1016/S0039-6060(05)80053-4
Allen R, Sarani B. Evaluation and management of intraabdominal hypertension. Curr Opin Crit Care 2020;26:192-6. https://doi.org/10.1097/MCC.0000000000000701
Abramson D, Scalea TM, Hitchcock R, Trooskin SZ, Henry SM, Greenspan J. Lactate clearance and survival following injury. J Trauma - Inj Infect Crit Care 1993;35:584-9. https://doi.org/10.1097/00005373-199310000-00014
Maluso P, Olson J, Sarani B. Abdominal Compartment Hypertension and Abdominal Compartment Syndrome. Crit Care Clin 2016;32:213-22. https://doi.org/10.1016/j.ccc.2015.12.001
Hirshberg A, Mattox KL. Planned reoperation for severe trauma. Ann Surg 1995;222:3-8. https://doi.org/10.1097/00000658-199507000-00002
Morris JA, Eddy VA, Rutherford EJ. The trauma celiotomy: The evolving concepts of damage control. Curr Probl Surg 1996;33:609-700. https://doi.org/10.1016/s0011-3840(96)80010-4
Butler FK, Holcomb JB, Shackelford S, Barbabella S, Bailey JA, Baker JB, et al. Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018. J Spec Oper Med 2018;18:37-55
Biffl WL, Fox CJ, Moore EE. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma Acute Care Surg 2015;78:1054-8. https://doi.org/10.1097/TA.0000000000000609
Hughes CW. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery 1954;36:65-8. https://doi.org/10.1097/TA.0000000000000770
Belenkiy SM, Batchinsky AI, Rasmussen TE, Cancio LC. Resuscitative endovascular balloon occlusion of the aorta for hemorrhage control: Past, present, and future. J Trauma Acute Care Surg 2015;79:S236-42. https://doi.org/10.5555/uri:pii:0039606054902664
Ordoñez CA, Manzano-Nunez R, Rodriguez F, Burbano P, García AF, Naranjo MP, et al. Current use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma. Rev Colomb Anestesiol 2017;45:30-8. https://doi.org/10.1016/j.rca.2017.07.012
Brenner ML, Moore LJ, DuBose JJ, Tyson GH, McNutt MK, Albarado RP, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg 2013;75:506-11. https://doi.org/10.1097/ta.0b013e31829e5416
Beyer CA, Hoareau GL, Kashtan HW, Wishy AM, Caples C, Spruce M, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in a swine model of hemorrhagic shock and blunt thoracic injury. Eur J Trauma Emerg Surg 2019. https://doi.org/10.1007/s00068-019-01185-3
Beyer CA, Johnson MA, Galante JM, DuBose JJ. Zones matter: Hemodynamic effects of zone 1 vs zone 3 resuscitative endovascular balloon occlusion of the aorta placement in trauma patients. Injury 2019;50:855-8. https://doi.org/10.1016/j.injury.2019.03.01
Ordoñez CA, Khan M, Cotton B, Perreira B, Brenner M, Ferrada P, et al. The Colombian Experience in Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): The Progression from a Large Caliber to a Low-Profile Device at a Level I Trauma Center. Shock 2020. https://doi.org/10.1097/SHK.0000000000001515
Manzano-Nunez R, Herrera-Escobar JP, DuBose J, Hörer T, Galvagno S, Orlas CP, et al. Could resuscitative endovascular balloon occlusion of the aorta improve survival among severely injured patients with post-intubation hypotension? Eur J Trauma Emerg Surg 2018;44:527-33. https://doi.org/10.1007/s00068-018-0947-2
Parra MW, Ordoñez CA, Herrera-Escobar JP, Gonzalez-Garcia A, Guben J. Resuscitative endovascular balloon occlusion of the aorta for placenta percreta/previa. J Trauma Acute Care Surg 2018;84:403-5. https://doi.org/10.1097/TA.0000000000001659
McGreevy DT, Abu-Zidan FM, Sadeghi M, Pirouzram A, Toivola A, Skoog P, et al. Feasibility and Clinical Outcome of Reboa in Patients with Impending Traumatic Cardiac Arrest. Shock 2019. https://doi.org/10.1097/SHK.0000000000001500
Ordoñez CA, Herrera-Escobar JP, Parra MW, Rodriguez-Ossa PA, Puyana JC, Brenner M. A severe traumatic juxtahepatic blunt venous injury. J Trauma Acute Care Surg 2016;80:674-6. https://doi.org/10.1097/TA.0000000000000979
García AF, Manzano-Nunez R, Orlas CP, Ruiz-Yucuma J, Londoño A, Salazar C, et al. Association of resuscitative endovascular balloon occlusion of the aorta (REBOA) and mortality in penetrating trauma patients. Eur J Trauma Emerg Surg 2020. https://doi.org/10.1007/s00068-020-01370-9
Meléndez JJ, Ordóñez CA, Parra M, Orlas CP, Manzano-Núñez R, García AF, et al. Balón de reanimación endovascular de aorta para pacientes en riesgo o en choque hemorrágico: experiencia en un centro de trauma de Latinoamérica. Rev Colomb Cir 2019:124-31. https://doi.org/10.30944/20117582.106
Ordoñez CA, Rodríguez F, Parra M, Herrera JP, Guzmán-Rodríguez M, Orlas C, et al. Resuscitative endovascular balloon of the aorta is feasible in penetrating chest trauma with major hemorrhage: Proposal of a new institutional deployment algorithm. J Trauma Acute Care Surg 2020;89:311-9. https://doi.org/10.1097/ta.0000000000002773
Bulger EM, Perina DG, Qasim Z, Beldowicz B, Brenner M, Guyette F, et al. Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians. Trauma Surg Acute Care Open 2019;4:e000376. https://doi.org/10.1136/tsaco-2019-000376
![REBOA as The New Fourth Pillar](https://colombiamedica.univalle.edu.co/colombiamedica311/public/journals/1/article_4353_cover_en_US.png)
Copyright (c) 2020 carlos ordoñez, Michael Parra, Jose Julian Serna, Fernando Rodriguez, Alberto Garcia, Alexander Salcedo, Yaset Caicedo, Natalia Padilla, Luis Fernando Pino, Adolfo González, Mario Alain Herrera, Mauricio Millán, Laureano Quintero, Fabian Hernandez, Ricardo Ferrada, Megan Brenner, Todd Rasmussen, Thomas Scalea, Rao Ivatury, John Holcomb, Juan Pablo Herrera, Claudia Patricia Orlas, Monica Guzman, Maria Josefa Franco, Juan Carlos Salamea, Fernando Miñan, Wilmer Botache, Neftali Vargas, Rolando Medina, David Scavo, Cecibel Cevallos, Ana Milena del Valle, Jenny Marcela Vidal, Juan Jose Melendez, Edison Angamarca, Juliana Ordoñez, Carlos Serna, Christian Delgado, Helmer Emilio Palacios, Luis Saldarriaga, Carlos Munar, Luis Eduardo Toro, Gonzalo Aristizabal (Author)
![Creative Commons License](http://i.creativecommons.org/l/by-nc/4.0/88x31.png)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The copy rights of the articles published in Colombia Médica belong to the Universidad del Valle. The contents of the articles that appear in the Journal are exclusively the responsibility of the authors and do not necessarily reflect the opinions of the Editorial Committee of the Journal. It is allowed to reproduce the material published in Colombia Médica without prior authorization for non-commercial use