Thread by @emeddoc

Just released in @TSACO_AAST: Clinical use of #REBOA in civilian trauma systems in the USA: joint statement from @ACSTrauma @EmergencyDocs @NAEMSP @NAEMSP (utilizing best available evidence & expert consensus opinion)

Full text: tsaco.bmj.com/content/4/1/e0…

Key points (thread): 1/x

This document focuses on the use of REBOA
in civilian trauma patients & integration w/i
civilian trauma systems in the US. Emphasis
is on patient safety as the most important principle
while recognizing the variability in trauma systems, centers, and clinician training 2/x

The quality of clinical evidence to support REBOA use in trauma
patients is poor with no Class I or II data demonstrating that it improves outcomes or survival compared with standard
treatment.

Many studies also do not report patient outcomes beyond the
initial resuscitation 3/x

REBOA is a tool that should be employed as part of
a larger system of damage control resuscitation, definitive
hemorrhage control, and postoperative critical care.

It is a temporary and not a definitive hemorrhage control procedure. 4/x

Aortic occlusion is a time-critical intervention which requires
rapid access to resuscitation and hemorrhage control.

Not appreciating the time-critical system elements to implementation of this seemingly straightforward procedure will likely lead to worse outcomes. 5/x

A multidisciplinary team-based approach is required for the development of REBOA protocols specific to the environment of care.

REBOA should only be placed by a physician/surgeon trained and qualified in this procedure integrated within an appropriate system of care 6/x

The major rate-limiting step to REBOA is the ability to safely
and efficiently cannulate the common femoral artery (CFA)
in a hypovolemic patient

Ultrasound guided percutaneous access is the preferred approach 7/x

Time limits of occlusion are critical - based on best-available evidence (limited in humans) & expert consensus opinion the patient should be able to proceed to definitive hemorrhage control within:

15 min for Zone 1 occlusion
30 min for Zone 3 occlusion

8/x

Do not delay definitive hemorrhage control to place REBOA unless the patient is in extremis and will not survive long enough to reach that care.

9/x

The team-not any one individual-is responsible for the care (incl monitoring for complications) of the patient undergoing REBOA. Appropriate use requires clear communication, education, and inclusion of all team members

REBOA programs will fail without the right system

10/x

Inter-facility transport & prehospital placement of #REBOA is possible-but within the right system of care in physician-led & -delivered teams that can achieve delivery to hemorrhage control w/i recommended time.

In the US currently, this is limited to a few agencies 11/x

Military-civilian partnership in reviewing outcomes of REBOA use is crucial - however military experience cannot be directly translated to the civilian environment.

Military use is dictated by the @JointTraumaSyst CPG: jts.amedd.army.mil/assets/docs/cp…

12/x

Training is crucial to attain skills in REBOA, and also to understand the systems approach to implementation.

Several training options exist, but should include core elements as described.

Courses should be supplemented by team-based training in individual institutions 13/x

It is imperative that individual systems maintain a robust QA/QI process.

Data should be contributed to national/multicenter trials (both positive and negative outcomes) to best inform future practice.

14/x

Note again that these are guidelines for the use of #REBOA within US civilian trauma systems.

They are based on best-available evidence and where this was not available, expert consensus opinion.

Continued efforts to conduct high-quality trials/evidence should continue

15/END