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Hilbert-Carius P, Streibert F, Ebert D, Vogt A, Beese M, Tongers J, Hofmann G, Braun J. [Effect of a 1-day "REBOA course" on the theoretical and practical skills for the prehospital REBOA setting : Experiences from the RIBCAP-HEMS project]. DIE ANAESTHESIOLOGIE 2023; 72:871-877. [PMID: 37999740 DOI: 10.1007/s00101-023-01359-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/06/2023] [Accepted: 10/23/2023] [Indexed: 11/25/2023]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents an endovascular procedure for aortic occlusion. The procedure can be used for temporary hemorrhage control as a bridge until surgical treatment for noncompressible abdominal or pelvic bleeding and to improve coronary and cerebral perfusion pressure during cardiopulmonary resuscitation. The prehospital administration is challenging and currently hardly possible in Germany. In the REBOA in bleeding and cardiac arrest in the prehospital care by helicopter emergency medical service (RIBCAP-HEMS) project, the prehospital use of REBOA will be tested in a feasibility study. This article describes the training course on the procedure in preparation for prehospital use, which was conducted before the start of the aforementioned feasibility study for the emergency physicians and paramedics (HEMS-TC) of the DRF Air Rescue Base in Halle (Saale). The course provided the necessary theoretical and practical skills to apply REBOA in the prehospital setting to patients in extremis in a safe, indications-conform and time-critical manner. The fact that all emergency physicians of the two air ambulances Christoph 84 and Christoph 85 in Halle are specialists in anesthesiology with corresponding experience in the placement of invasive arterial catheters proved to be advantageous. The training course was able to significantly improve the theoretical and practical abilities of the participants. The results of the currently ongoing study must show whether the procedure can be usefully integrated into the prehospital care of patients in extremis.
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Affiliation(s)
- Peter Hilbert-Carius
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Schmerztherapie, Bergmannstrost BG Klinikum Halle (Saale) gGmbH, Merseburgerstr. 165, 06112, Halle (Saale), Deutschland.
- DRF Luftrettung, Station Halle, Christoph Sachsen-Anhalt (CHX 84) und Christoph Halle (CHX 85), Halle (Saale), Deutschland.
| | - Fridolin Streibert
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Schmerztherapie, Bergmannstrost BG Klinikum Halle (Saale) gGmbH, Merseburgerstr. 165, 06112, Halle (Saale), Deutschland
- DRF Luftrettung, Station Halle, Christoph Sachsen-Anhalt (CHX 84) und Christoph Halle (CHX 85), Halle (Saale), Deutschland
| | - Daniel Ebert
- DRF Luftrettung, Station Halle, Christoph Sachsen-Anhalt (CHX 84) und Christoph Halle (CHX 85), Halle (Saale), Deutschland
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Alexander Vogt
- Universitätsklinik und Poliklinik für Innere Medizin III (Kardiologie, Angiologie, Internistische Intensivmedizin), Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Matthias Beese
- DRF Luftrettung, Station Halle, Christoph Sachsen-Anhalt (CHX 84) und Christoph Halle (CHX 85), Halle (Saale), Deutschland
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Jörn Tongers
- Universitätsklinik und Poliklinik für Innere Medizin III (Kardiologie, Angiologie, Internistische Intensivmedizin), Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Gunther Hofmann
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Friedrich-Schiller-Universität Jena, Jena, Deutschland
| | - Jörg Braun
- DRF Luftrettung, Filderstadt, Deutschland
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Steffen R, Knapp J, Hänggi M, Iten M. [Use of the REBOA catheter for uncontrollable upper gastrointestinal bleeding with hemorrhagic shock]. DIE ANAESTHESIOLOGIE 2023; 72:332-337. [PMID: 36988637 PMCID: PMC10181967 DOI: 10.1007/s00101-023-01278-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/09/2023] [Accepted: 01/18/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Richard Steffen
- Universitätsklinik für Intensivmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
- Klinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Universität Bern, 3010, Bern, Schweiz
| | - Jürgen Knapp
- Klinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Universität Bern, 3010, Bern, Schweiz.
- Schweizerische Rettungsflugwacht, Rega, Zürich, Schweiz.
| | - Matthias Hänggi
- Universitätsklinik für Intensivmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Manuela Iten
- Universitätsklinik für Intensivmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
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Knapp J, Jakob DA, Haltmeier T, Lehmann B, Hautz WE. [Resuscitative endovascular balloon occlusion of the aorta in severely injured patients in the emergency trauma room: a case series]. Anaesthesist 2022; 71:599-607. [PMID: 35254464 PMCID: PMC9352627 DOI: 10.1007/s00101-022-01100-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/01/2022] [Accepted: 02/13/2022] [Indexed: 11/27/2022]
Abstract
Hemorrhage is the cause of death in 30-40% of severely injured patients due to trauma and the most frequent avoidable cause of death. In civilian emergency medical services, the majority of life-threatening hemorrhages are found in incompressible body regions (e.g. abdomen and pelvis). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has therefore been discussed in recent years as a lifesaving procedure for temporary bleeding control in multiple trauma patients. Since August 2020 REBOA is implented in the treatment of seriously injured patients in the emergency department of the University Hospital of Bern. In this case series we report on our experiences in all seven patients in whom we performed this procedure during the first year.
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Affiliation(s)
- Jürgen Knapp
- Klinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz.
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Spital Schwyz, Schwyz, Schweiz.
- Klinik für Anästhesiologie und Schmerztherapie, Universitätsspital Bern, Universität Bern, Freiburgstraße, 3010, Bern, Schweiz.
| | - Dominik A Jakob
- Universitäres Notfallzentrum, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Tobias Haltmeier
- Klinik für Viszerale Chirurgie und Medizin, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Beat Lehmann
- Universitäres Notfallzentrum, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Wolf E Hautz
- Universitäres Notfallzentrum, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
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Michael M, Bax S, Finke M, Hoffmann M, Kornstädt S, Kümpers P, Kumle B, Laaf T, Reindl M, Schunk D, Pin M, Bernhard M. Aktuelle Ist-Analyse zur Situation des nichttraumatologischen Schockraummanagements in Deutschland. Notf Rett Med 2022. [DOI: 10.1007/s10049-020-00827-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Zusammenfassung
Einleitung
In Notaufnahmen kommen bundesweit nichttraumatologische kritisch kranke Patienten zur Aufnahme. Zur Struktur, Organisation und Ausstattung des nichttraumatologischen Schockraummanagements ist bisher wenig bekannt. Mittels einer Umfrage sollte daher der Ist-Zustand analysiert werden.
Methodik
Durch die Arbeitsgruppe „Schockraum“ der Deutschen Gesellschaft Interdisziplinäre Notfall- und Akutmedizin (DGINA) wurde mittels E‑Mail den 420 ärztlichen Leiter*Innen des DGINA-Mitgliederregisters eine Onlineumfrage zugesendet. Zwei Wochen nach initialem Anschreiben erfolgte eine Erinnerung. Die Ergebnisse wurden in einer anonymisierten Datenbank extrahiert und ausgewertet.
Ergebnisse
Insgesamt lag die Rücklaufquote mit 131 verwertbaren Antworten bei 31 %. Die Umfrage erfasste Krankenhäuser der Basis- (24 %), erweiterten (39 %) und umfassenden Notfallversorgung (37 %). Korrespondierend zur Versorgungsstufe stiegen die jährlichen Patientenkontakte (21.000 vs. 31.000 vs. 39.000), die Monitorplätze in den Notaufnahmen (9 ± 4 vs. 13 ± 6 vs. 18 ± 10), die Betten der assoziierten Notaufnahmestationen (4 ± 5 vs. 10 ± 17 vs. 13 ± 12), die verfügbaren Schockräume (1 ± 1 vs. 2 ± 1 vs. 3 ± 1) und deren Größe (31 ± 16 vs. 35 ± 9 vs. 38 ± 14 m2) an. Hinsichtlich verschiedener Ausstattungsmerkmale (z. B. Röntgenlafette: 58 vs. 65 vs. 78 %, Computertomographie im Schockraum: 6 vs. 12 vs. 27 %) zeigten sich deutliche Unterschiede in Abhängigkeit von der Versorgungsstufe. Während Kühlungssysteme in 30 % in allen Versorgungsstufen vorgehalten wurden, fanden sich andere Ausstattungsmerkmale (z. B. Videolaryngoskopie: 65 vs. 80 vs. 86 %, Bronchoskopie: 29 vs. 22 vs. 45 %) und spezielle Notfallprozeduren (z. B. REBOA [„resuscitative endovascular balloon occlusion of the aorta“]: 3 vs. 5 vs. 12 %, ACCD [„automated chest compression device“]: 26 vs. 57 vs. 61 %) häufiger in höheren Versorgungsstufen.
Schlussfolgerung
Die vorliegenden Ergebnisse zeigen erstmals den Ist-Zustand der nichttraumatologischen Schockraumversorgung in verschiedenen Versorgungsstufen in Deutschland. Empfehlungen zu Ausstattungsmerkmalen für das nichttraumatologische Schockraummanagement müssen zukünftig formuliert werden.
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Abstract
Resuscitation rooms in central emergency admissions are the first point of contact for potentially severely or multiply injured patients. Here priority is given to the interdisciplinary treatment of these patients, which includes the structured and standardized hospital admission as well as the appropriate initial diagnostics and treatment of potentially life-threatening conditions. The resuscitation room is a central vital link between the prehospital and internal hospital treatment chain. This article describes the core tasks of the resuscitation room team as well as concepts and strategies of initial treatment of severely injured and polytrauma patients.
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Hilbert-Carius P, McGreevy DT, Abu-Zidan FM, Hörer TM. Pre-hospital CPR and early REBOA in trauma patients - results from the ABOTrauma Registry. World J Emerg Surg 2020; 15:23. [PMID: 32228640 PMCID: PMC7104487 DOI: 10.1186/s13017-020-00301-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/28/2020] [Indexed: 11/30/2022] Open
Abstract
Background Severely injured trauma patients suffering from traumatic cardiac arrest (TCA) and requiring cardiopulmonary resuscitation (CPR) rarely survive. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) performed early after hospital admission in patients with TCA is not well-defined. As the use of REBOA increases, there is great interest in knowing if there is a survival benefit related to the early use of REBOA after TCA. Using data from the ABOTrauma Registry, we aimed to study the role of REBOA used early after hospital admission in trauma patients who required pre-hospital CPR. Methods Retrospective and prospective data on the use of REBOA were collected from the ABOTrauma Registry from 11 centers in seven countries globally between 2014 and 2019. In all patients with pre-hospital TCA, the predicted probability of survival, calculated with the Revised Injury Severity Classification II (RISC II), was compared with the observed survival rate. Results Of 213 patients in the ABOTrauma Registry, 26 patients (12.2%) who had received pre-hospital CPR were identified. The median (range) Injury Severity Score (ISS) was 45.5 (25–75). Fourteen patients (54%) had been admitted to the hospital with ongoing CPR. Nine patients (35%) died within the first 24 h, while seventeen patients (65%) survived post 24 h. The survival rate to hospital discharge was 27% (n = 7). The predicted mortality using the RISC II was 0.977 (25 out of 26). The observed mortality (19 out of 26) was significantly lower than the predicted mortality (p = 0.049). Patients not responding to REBOA were more likely to die. Only one (10%) out of 10 non-responders survived. The survival rate in the 16 patients responding to REBOA was 37.5% (n = 6). REBOA with a median (range) duration of 45 (8–70) minutes significantly increases blood pressure from the median (range) 56.5 (0–147) to 90 (0–200) mmHg. Conclusions Mortality in patients suffering from TCA and receiving REBOA early after hospital admission is significantly lower than predicted by the RISC II. REBOA may improve survival after TCA. The use of REBOA in these patients should be further investigated.
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Affiliation(s)
- Peter Hilbert-Carius
- Department of Anesthesiology, Emergency and Intensive Care Medicine, Bergmannstrost BG-Klinikum Halle gGmbH, Merseburgerstr. 165, 06112, Halle, Germany.
| | - David T McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Science, UAE University, Al-Ain, United Arab Emirates
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Özkurtul O, Staab H, Osterhoff G, Ondruschka B, Höch A, Josten C, Fakler JKM. Technical limitations of REBOA in a patient with exsanguinating pelvic crush trauma: a case report. Patient Saf Surg 2019; 13:25. [PMID: 31285757 PMCID: PMC6592001 DOI: 10.1186/s13037-019-0204-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/07/2019] [Indexed: 11/10/2022] Open
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.
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Affiliation(s)
- Orkun Özkurtul
- 1Department of Orthopedic, Trauma, and Plastic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Holger Staab
- 2Department of Visceral, Transplantation, Thorax and Vascular Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Georg Osterhoff
- 1Department of Orthopedic, Trauma, and Plastic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Benjamin Ondruschka
- 3Institute of Legal Medicine, Medical Faculty University of Leipzig, Johannisallee 28, 04103 Leipzig, Germany
| | - Andreas Höch
- 1Department of Orthopedic, Trauma, and Plastic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Christoph Josten
- 1Department of Orthopedic, Trauma, and Plastic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Johannes Karl Maria Fakler
- 1Department of Orthopedic, Trauma, and Plastic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
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Hoareau GL, Tibbits EM, Beyer CA, Simon MA, DeSoucy ES, Faulconer ER, Neff LP, Grayson JK, Stewart IJ, Williams TK, Johnson MA. Resuscitative Endovascular Balloon Occlusion of the Aorta: Review of the Literature and Applications to Veterinary Emergency and Critical Care. Front Vet Sci 2019; 6:197. [PMID: 31275952 PMCID: PMC6594359 DOI: 10.3389/fvets.2019.00197] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 06/03/2019] [Indexed: 11/13/2022] Open
Abstract
While hemorrhagic shock might be the result of various conditions, hemorrhage control and resuscitation are the corner stone of patient management. Hemorrhage control can prove challenging in both the acute care and surgical settings, especially in the abdomen, where no direct pressure can be applied onto the source of bleeding. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a promising replacement to resuscitative thoracotomy (RT) for the management of non-compressible torso hemorrhage in human trauma patients. By inflating a balloon at specific levels (or zones) of the aorta to interrupt blood flow, hemorrhage below the level of the balloon can be controlled. While REBOA allows for hemorrhage control and augmentation of blood pressure cranial to the balloon, it also exposes caudal tissue beds to ischemia and the whole body to reperfusion injury. We aim to introduce the advantages of REBOA while reviewing known limitations. This review outlines a step-by-step approach to REBOA implementation, and discusses common challenges observed both in human patients and during translational large animal studies. Currently accepted and debated indications for REBOA in humans are discussed. Finally, we review possible applications for veterinary patients and how REBOA has the potential to be translated into clinical veterinary practice.
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Affiliation(s)
- Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States
| | - Emily M Tibbits
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Carl A Beyer
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Meryl A Simon
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Erik S DeSoucy
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | | | - Lucas P Neff
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States
| | - Ian J Stewart
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - M Austin Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, United States
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Resuscitative endovascular balloon occlusion of the aorta: an option for noncompressible torso hemorrhage? Curr Opin Anaesthesiol 2019; 32:213-226. [PMID: 30817398 DOI: 10.1097/aco.0000000000000699] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Hemorrhage is the major cause of early death in severely injured patients. In civilian emergency medical services, the majority of life-threatening bleedings are found in noncompressible body regions (e.g. abdomen and pelvis). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has therefore been discussed in recent years as a possible lifesaving procedure and numerous studies, meta-analyses and guidelines have been published. In this review, the data situation of REBOA in the management of bleeding trauma patients is discussed and practical implementation is depicted. RECENT FINDINGS The typical indication for REBOA is a traumatic life-threatening hemorrhage below the diaphragm in patients unresponsive or only transiently responsive to the usual conservative therapeutic measures. REBOA appears to be a safe and effective procedure to reduce blood loss and stabilize the patient's hemodynamic status. However, surgical hemostasis has to be achieved within 30-60 min after occlusion of the aorta. Data on clear advantages of REBOA over resuscitative thoracostomy are inconclusive. SUMMARY REBOA could play an important role in the management of the severely bleeding patient in the future. Together with transfusion and therapy of coagulation disorders, REBOA may be an additional tool in the anesthetist's hands for trauma management in interprofessional care concepts.
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Kulla M. Reanimation nach Trauma: Nicht unter Druck setzen lassen! Anaesthesist 2019; 68:129-131. [DOI: 10.1007/s00101-019-0541-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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