Implementation and Adaptation of Pathway of Resuscitative Endovascular Balloon Occlusion of the Aorta after Traumatic Injury

Abstract

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an invented method to facilitate a minimally invasive occlusion of the aorta to stop a life-threatening hemorrhage. This review described an established pathway for noncompressible exsanguination (REBOA procedures) in trauma patients at a Level 1 trauma center. A detailed description starting from the structural changes of the hospital and facilities itself, the initial thoughts, implementation of the process, and continuous revision and improvement of guidelines were discussed. A multidisciplinary core team consisting of trauma surgeons, anesthesiologists, interventional radiologists, and operating room (OR) staff developed step-by-step clinical practice guidelines for using REBOA at our trauma center. A comprehensive training program for specialized procedural training was implemented to ensure the competency of all relevant medical personnel in managing trauma patients. The REBOA guidelines underwent plan-do-check-act quality cycle improvement until the latest guidelines were reached with each use of REBOA in a trauma patient, leading to further auditing of the guidelines to identify areas for improvement. The current review discusses the critical role of adopting innovative technologies and adapting protocols in trauma care, particularly for vulnerable patients with a high risk of morbidity and mortality. Continuous process improvement, procedural refinement, and evolving guidelines are essential prerequisites for optimizing patient outcomes. We described a valuable framework for other trauma programs to implement and adapt similar endovascular bleeding control approaches, thereby potentially enhancing patient care.

Keywords: Aortic rupture; hemorrhagic control; hemostasis; implementation; resuscitation; resuscitative endovascular balloon occlusion of the aorta; trauma.

Figure 1

Resuscitative endovascular balloon occlusion of the aorta activation and management pathway. REBOA: Resuscitative endovascular balloon occlusion of the aorta. MTP: Massive transfusion protocol, CPR: Cardiopulmonary resuscitation, ECG: Electrocardiogram, FAST: Focused assessment with sonography for trauma, TICU: Trauma intensive care unit, IR: Interventional radiology

Figure 2

A try for resuscitative endovascular balloon occlusion of the aorta training

Figure 3

(a) Clinical guidance and task allocation. (b) Approach for managing massive bleeding. REBOA: Resuscitative endovascular balloon occlusion of the aorta, IR: Interventional radiology, MTP: Massive transfusion protocol, TXA: Tranexamic acid, FAST: Focused assessment with sonography for trauma

Figure 4

Hospital pathway for treatment utilizing resuscitative endovascular balloon occlusion of the aorta. REBOA: Resuscitative endovascular balloon occlusion of the aorta, CT: Computed tomography

Figure 5

Timeline of resuscitative endovascular balloon occlusion of the aorta in our hospital. REBOA: Resuscitative endovascular balloon occlusion of the aorta, HTC: Hamad Trauma Center