Technical limitations of REBOA in a patient with exsanguinating pelvic crush trauma: a case report

Abstract

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective adjunct in hemodynamic unstable patients with uncontrolled and non-compressible torso hemorrhage promoting temporary stability during injury repair. The aim of our study was to analyze real life usability of REBOA based on a case report and to review the literature with respect to its possibilities and limitations.

Case presentation: We present the case of a 17-years old female patient who sustained a severe roll-over trauma and pelvic crush injury as a bicyclist by a truck. Upon arrival of the first responders, the patient was awake, alert, and following commands.Subsequent to lifting the truck, the patient became hypotensive and required cardiopulmonary resuscitation, application of a pelvic binder, and endotracheal intubation at the accident scene. She was then admitted by ambulance to our trauma center under ongoing resuscitative measures. After primary survey, it was decided to perform a REBOA with surgical approach to the left femoral artery. Initial insertion of the catheter was successful but could not be advanced beyond the inguinal region. Hence, the patient was transferred to the operating room (OR) but died despite maximum therapy. In the OR and later autopsy, we found a long-distance ruptured and dehiscent external iliac artery with massive bleeding into the pelvis in the context of a bilateral vertical shear fractured pelvic bone.

Conclusion: REBOA can be a useful adjunct but there is a major limitation with potential vascular injury after pelvic trauma. In these situations, cross-clamping the proximal aorta or pre-peritoneal pelvic packing as "traditional" approaches of hemorrhage control during resuscitation may be the most considerable methods for temporary stabilization in severely injured trauma patients. More clinical and cadaveric studies are needed to further understand indications and limitations of REBOA after severe pelvic trauma.

Fig. 1

REBOA Zones reproduced with permission from Stannard et al. (Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an Adjunct for Hemorrhagic Shock. The Journal of Trauma: Injury, Infection, and Critical Care. 1. Dezember 2011;71 [6]:1869–72)

Fig. 2

Leipzig Pelvic Trauma Algorithm in patients with hemorrhagic shock

Fig. 3

Loose catheter in the pelvis during emergency laparotomy in the operation room

Fig. 4

Acetabulum fracture with impacted femoral head left-sided. LS: Lumbar spine, Sa: Sacrum, Im: Ileum, Ac: Acetabulum, FH: Femur head, *: fracture lines

Fig. 5

Fractured and unstable pelvis right-sided. LS: Lumbar spine, Sa: Sacrum, Im: Ileum, *: fracture lines