Resuscitative endovascular balloon of the aorta is feasible in penetrating chest trauma with major hemorrhage: Proposal of a new institutional deployment algorithm

Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in a multidisciplinary approach for management of traumatic haemorrhagic shock: 10-year retrospective experience from a French level 1 trauma centre

BACKGROUND

The present study investigated an institutional multidisciplinary strategy for managing traumatic haemorrhagic shock by integrating the placement of REBOA (resuscitative endovascular balloon occlusion of the aorta) by anaesthesiologist-intensivists.

METHODS

All severe trauma patients who received percutaneous REBOA placement between January 2013 and December 2022 in our level 1 trauma centre were retrospectively analysed. The data collected included the clinical context, indications and location of REBOA, durations of aortic occlusion (AO), choice of haemostatic procedures and surgical teams, and specific complications.

RESULTS

In total, 38 trauma patients were included in the present study (mean age = 41 years [standard deviation = 21 years], 31 [82 %] were male, and median injury severity score was 62.5 [inter-quartile range (IQR) = 45-75]). REBOA was always placed by anaesthesiologist-intensivists, who comprised 68 % of the senior physicians (13/19) in our trauma team over the period. Twenty-eight AOs (74 %) were performed in zone 1 and 10 (26 %) in zone 3. Twelve patients (32 %) received REBOA upon circulatory arrest. Routes following REBOA placement comprised: computed tomography scan = 47 %, operating room = 34 %, angiography = 3 %, emergency room thoracotomy = 5 %, and prematurely died = 11 %. Duration of AO was 38 min (IQR = 32-44 min) in zone 1 and 78 min (IQR = 48-112 min) in zone 3. Mortality rate was 66 % (95 % CI 51-81 %) and higher in cases of AO in zone 1 (79 % versus 30 %, p = 0.018) or concomitant with circulatory arrest (92 % versus 54 %, p = 0.047). No ischemic limb needed an intervention and three endothelial injuries required delayed endovascular stenting.

CONCLUSIONS

Percutaneous REBOA placement by anaesthesiologist-intensivists included in the multidisciplinary management of traumatic haemorrhagic shock was associated with acceptable time of AO and local complications similar to those observed in other series.

Damage control thoracic surgery: What you need to know

ABSTRACT

Damage control surgery in trauma prioritizes patient stabilization through an initial temporizing surgical approach to rapidly control hemorrhage and contamination, minimizing intraoperative time to allow for resuscitation and the correction of hypothermia, coagulopathy, and acidosis in the intensive care unit. This is followed by definitive repair of injuries once physiological parameters have improved. While damage control techniques for traumatic intra-abdominal and extremity injuries are well established and frequently utilized, the same cannot be said for damage control thoracic surgery. The complexity of thoracic injuries, the intricate decision making process, the level of surgical expertise required, and potential complications make damage control thoracic surgery particularly challenging. However, advances in surgical techniques, improvements in perioperative care, and the emergence of adjuncts such as extracorporeal membrane oxygenation have significantly enhanced decision making and underscored the importance of timely and decisive intervention in damage control thoracic surgery to optimize patient outcomes. This review aims to provide a comprehensive overview of damage control thoracic surgery, detailing the principles, indications, operative techniques, perioperative management, and the integration of advanced therapies to improve outcomes in patients with severe thoracic injuries.

When Every Minute Counts: REBOA Before Surgery Is Independently Associated With a 15-Minute Delay in Time to Definitive Hemorrhage Control

INTRODUCTION

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing hemorrhage control intervention, but its inevitable effect on time to operating room (OR) has not been assessed. The aim of our study is to assess the impact of undergoing REBOA before surgery (RBS) on time to definitive hemorrhage control surgery.

METHODS

In this retrospective analysis of 2017-2021 ACS-TQIP database, all adult (≥18 years) patients who underwent emergency hemorrhage control laparotomy (≤4 hours of admission) and received early blood products (≤4 hours) were included, and patients with severe head injury (Head-abbreviated injury score > 2) were excluded. Patients were stratified into those who did (RBS) vs those who did not undergo REBOA before surgery (No-RBS). Primary outcome was time to laparotomy. Secondary outcomes were complications and mortality. Multivariable linear and binary logistic regression analyses were performed to identify the independent associations between RBS and outcomes.

RESULTS

A total of 32,683 patients who underwent emergency laparotomy were identified (RBS: 342; No-RBS: 32,341). The mean age was 39 (16) years, 78% were male, mean SBP was 107 (34) mmHg, and the median injury severity score was 21 [14-29]. The median time to emergency hemorrhage control surgery was 50 [32-85] minutes. Overall complication rate was 16% and mortality was 19%. On univariate analysis, RBS group had longer time to surgery (RBS 56 [41-89] vs No-RBS 50 [32-85] minutes, P < 0.001). On multivariable analysis, RBS was independently associated with a longer time to hemorrhage control surgery (β + 14.5 [95%CI 7.8-21.3], P < 0.001), higher odds of complications (aOR = 1.72, 95%CI = 1.27-2.34, P < 0.001), and mortality (aOR = 3.42, 95%CI = 2.57-4.55, P < 0.001).

CONCLUSION

REBOA is independently associated with longer time to OR for hemorrhaging trauma patients with an average delay of 15 minutes. Further research evaluating center-specific REBOA volume and utilization practices, and other pertinent system factors, may help improve both time to REBOA as well as time to definitive hemorrhage control across US trauma centers.

LEVEL OF EVIDENCE

III.

STUDY TYPE

Epidemiologic.

The Role of Resuscitative Endovascular Balloon Occlusion of the Aorta

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been utilized by trauma surgeons at the bedside for over a decade in both civilian and military settings. Both translational and clinical research suggest it is superior to resuscitative thoracotomy for specific patient populations. Technological advancements in recent years have significantly enhanced the safety profile of REBOA. Resuscitative balloon occlusion of the aorta has also swiftly found implementation in patients in shock from non-traumatic hemorrhage.

Is REBOA the Last Card to Control a Massive Gastrointestinal Bleeding?

INTRODUCTION

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential tool for the management of massive gastrointestinal bleeding (MGB). This study aims to describe the experience of the use of REBOA as adjunctive therapy in patients with MGB and to evaluate its effectiveness.

METHODS

Serial cases of patients with hemorrhagic shock secondary to MGB in whom REBOA was placed were collected. Patient demographics, bleeding severity, etiology, management, and clinical outcomes were recorded.

RESULTS

Between 2017 and 2020, five cases were analyzed. All patients had a severe gastrointestinal bleeding (Glasgow Blatchford Bleeding Score range 12-17; Clinical Rockal Score range 5-9). The etiologies of MGB were perforated gastric or duodenal ulcers, esophageal varices, and vascular lesions. Systolic blood pressure increased after REBOA placement and total occlusion time was 25-60 min. REBOA provided temporary hemorrhage control in all cases and allowed additional hemostatic maneuvers to be performed. Three patients survived more than 24 h. All patients died in index hospitalization. The main cause of death was related to hemorrhagic shock.

CONCLUSIONS

Endovascular aortic occlusion can work as a bridge to further resuscitation and attempts at hemostasis in patients with MGB. REBOA provides hemodynamic support and may be used simultaneously with other hemostatic maneuvers, facilitating definitive hemorrhage control.

Critical systolic blood pressure threshold for endovascular aortic occlusion-A multinational analysis to determine when to place a REBOA

BACKGROUND

Systolic blood pressure (SBP) is a potential indicator that could guide when to use a resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma patients with life-threatening injuries. This study aims to determine the optimal SBP threshold for REBOA placement by analyzing the association between SBP pre-REBOA and 24-hour mortality in severely injured hemodynamically unstable trauma patients.

METHODS

We performed a pooled analysis of the aortic balloon occlusion (ABO) trauma and AORTA registries. These databases record the details related to the use of REBOA and include data from 14 countries worldwide. We included patients who had suffered penetrating and/or blunt trauma. Patients who arrived at the hospital with a SBP pre-REBOA of 0 mm Hg and remained at 0 mm Hg after balloon inflation were excluded. We evaluated the impact that SBP pre-REBOA had on the probability of death in the first 24 hours.

RESULTS

A total of 1,107 patients underwent endovascular aortic occlusion, of these, 848 met inclusion criteria. The median age was 44 years (interquartile range [IQR], 27-59 years) and 643 (76%) were male. The median injury severity score was 34 (IQR, 25-45). The median SBP pre-REBOA was 65 mm Hg (IQR, 49-88 mm Hg). Mortality at 24 hours was reported in 279 (32%) patients. Math modeling shows that predicted probabilities of the primary outcome increased steadily in SBP pre-REBOA below 100 mm Hg. Multivariable mixed-effects analysis shows that when SBP pre-REBOA was lower than 60 mm Hg, the risk of death was more than 50% (relative risk, 1.5; 95% confidence interval, 1.17-1.92; p = 0.001).

DISCUSSION

In patients who do not respond to initial resuscitation, the use of REBOA in SBPs between 60 mm Hg and 80 mm Hg may be a useful tool in resuscitation efforts before further decompensation or complete cardiovascular collapse. The findings from our study are clinically important as a first step in identifying candidates for REBOA.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Non-compressible truncal and junctional hemorrhage: A retrospective analysis quantifying potential indications for advanced bleeding control in Dutch trauma centers

BACKGROUND

Truncal and junctional hemorrhage is the leading cause of potentially preventable deaths in trauma patients. To reduce this mortality, the application of advanced bleeding control techniques, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), junctional tourniquets, Foley catheters, or hemostatic agents should be optimized. This study aimed to identify trauma patients with non-compressible truncal and junctional hemorrhage (NCTJH) who might benefit from advanced bleeding control techniques during initial trauma care. We hypothesized that there is a substantial cohort of Dutch trauma patients that can possibly benefit from advanced bleeding control techniques.

METHODS

Adult trauma patients with an Abbreviated Injury Scale ≥3 in the torso, neck, axilla, or groin region, who were presented between January 1st, 2014 and December 31st, 2018 to two Dutch level-1 trauma centers, were identified from the Dutch Trauma Registry. Potential indications for advanced bleeding control in patients with NCTJH were assessed by an expert panel of three trauma surgeons based on injury characteristics, vital signs, response to resuscitation, and received treatment.

RESULTS

In total, 1719 patients were identified of whom 249 (14.5 %) suffered from NCTJH. In 153 patients (60.6 %), hemorrhagic shock could have been mitigated or prevented with advanced bleeding control techniques. This group was younger and more heavily injured: median age of 40 versus 48 years and median ISS 33 versus 22 as compared to the entire cohort. The mortality rate in these patients was 31.8 %. On average, each of the included level-1 trauma centers treated an NCTJH patient every 24 days in whom a form of advanced bleeding control could have been beneficial.

CONCLUSIONS

More than half of included Dutch trauma patients with NCTJH may benefit from in-hospital application of advanced bleeding control techniques, such as REBOA, during initial trauma care. Widespread implementation of these techniques in the Dutch trauma system may contribute to reduction of mortality and morbidity from non-compressible truncal and junctional hemorrhage.

Outcomes and potential for improvement in the prehospital treatment of penetrating chest injuries in a European metropolitan area: A retrospective analysis of 2009 - 2017

BACKGROUND

Trauma is the leading cause of death in patients <45 years living in high-resource settings. However, penetrating chest injuries are still relatively rare in Europe - with an upwards trend. These cases are of particular interest to emergency medical services (EMS) due to available invasive treatment options like chest tube placement or resuscitative thoracotomy. To date, there is no sufficient data from Austria regarding penetrating chest trauma in a metropolitan area, and no reliable source to base decisions regarding further skill proficiency training on.

METHODS

For this retrospective observational study, we screened all trauma emergency responses of the Viennese EMS between 01/2009 and 12/2017 and included all those with a National Advisory Committee for Aeronautics (NACA) score ≥ IV (= potentially life-threatening). Data were derived from EMS mission documentations and hospital files, and for those cases with the injuries leading to cardiopulmonary resuscitation (CPR), we assessed the EMS cardiac arrest registry and consulted a forensic physician.

RESULTS

We included 480 cases of penetrating chest injuries of NACA IV-VII (83% male, 64% > 30 years old, 74% stab wounds, 16% cuts, 8% gunshot wounds, 56% inflicted by another party, 26% self-inflicted, 18% unknown). In the study period, the incidence rose from 1.4/100,000 to 3.5/100,000 capita, and overall, about one case was treated per week. In the cases with especially severe injury patterns (= NACA V-VII, 43% of total), (tension-)pneumothorax was the most common injury (29%). The highest mortality was seen in injuries to pulmonary vessels (100%) or the heart (94%). Fifty-eight patients (12% of total) deceased, whereas in 15 cases, the forensic physician stated survival could theoretically have been possible. However, only five of these CPR patients received at least unilateral thoracostomy. Regarding all penetrating chest injuries, thoracostomy had only been performed in eight patients.

CONCLUSIONS

Severe cases of penetrating chest trauma are rare in Vienna and happened about once a week between 2009 and 2017. Both incidence and case load increased over the years, and potentially life-saving invasive procedures were only reluctantly applied. Therefore, a structured educational and skill retention approach aimed at both paramedics and emergency physicians should be implemented.

TRIAL REGISTRATION

Retrospective analysis without intervention.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Resuscitative balloon occlusion of the aorta in the modern era: Expanding indications, optimal techniques, unresolved issues, and current results

Resuscitative endovascular balloon occlusion of the aorta has been used by trauma surgeons at the bedside for more than a decade in civilian and military settings. Translational and clinical research suggests it is superior to resuscitative thoracotomy for select patients. Clinical research suggests outcomes are superior in patients who received resuscitative balloon occlusion of the aorta compared with those who did not. Technology has advanced considerably in the past several years, leading to the improved safety profile and wider adoption of resuscitative balloon occlusion of the aorta. In addition to trauma patients, resuscitative balloon occlusion of the aorta has been rapidly implemented for patient with nontraumatic hemorrhage.

Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies

Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.

Systematic review to evaluate algorithms for REBOA use in trauma and identify a consensus for patient selection

Background

Patient selection for resuscitative endovascular balloon occlusion of the aorta (REBOA) has evolved during the last decade. A recent multicenter collaboration to implement the newest generation REBOA balloon catheter identified variability in patient selection criteria. The aims of this systematic review were to compare recent REBOA patient selection guidelines and to identify current areas of consensus and variability.

Methods

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of clinical practice guidelines for REBOA patient selection in trauma. Published algorithms from 2015 to 2022 and institutional guidelines from a seven-center REBOA collaboration were compiled and synthesized.

Results

Ten published algorithms and seven institutional guidelines on REBOA patient selection were included. Broad consensus exists on REBOA deployment for blunt and penetrating trauma patients with non-compressible torso hemorrhage refractory to blood product resuscitation. Algorithms diverge on precise systolic blood pressure triggers for early common femoral artery access and REBOA deployment, as well as the use of REBOA for traumatic arrest and chest or extremity hemorrhage control.

Conclusion

Although our convenience sample of institutional guidelines likely underestimates patient selection variability, broad consensus exists in the published literature regarding REBOA deployment for blunt and penetrating trauma patients with hypotension not responsive to resuscitation. Several areas of patient selection variability reflect individual practice environments.

Level of evidence

Level 5, systematic review.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Resuscitative endovascular balloon occlusion of the aorta in civilian pre-hospital care: a systematic review of the literature

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a damage control tool with a potential role in the hemodynamic resuscitation of severely ill patients in the civilian pre-hospital setting. REBOA ensures blood flow to vital organs by early proximal control of the source of bleeding. However, there is no consensus on the use of REBOA in the pre-hospital setting. This article aims to perform a systematic review of the literature about the feasibility, survival, indications, complications, and potential candidates for civilian pre-hospital REBOA.

Methods

A literature search was conducted using Medline, EMBASE, LILACS and Web of Science databases. Primary outcome variables included overall survival and feasibility. Secondary outcome variables included complications and potential candidates for endovascular occlusion.

Results

The search identified 8 articles. Five studies described the use of REBOA in pre-hospital settings, reporting a total of 47 patients in whom the procedure was attempted. Pre-hospital REBOA was feasible in 68–100% of trauma patients and 100% of non-traumatic patients with cardiac arrest. Survival rates and complications varied widely. Pre-hospital REBOA requires a coordinated and integrated emergency health care system with a well-trained and equipped team. The remaining three studies performed a retrospective analysis identifying 784 potential REBOA candidates.

Conclusions

Pre-hospital REBOA could be a feasible intervention for a significant portion of severely ill patients in the civilian setting. However, the evidence is limited. The impact of pre-hospital REBOA should be assessed in future studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00836-3.

Resuscitative Endovascular Balloon Occlusion of the Aorta in Penetrating Trauma

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary hemorrhage control via aortic occlusion. Existing REBOA literature focuses on blunt trauma without a clearly defined role in penetrating trauma. This study compared clinical/injury data and outcomes after REBOA in penetrating vs blunt trauma.

STUDY DESIGN

All patients in the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) database, an observational American Association for the Surgery of Trauma dataset of trauma patients requiring aortic occlusion, who underwent REBOA were included (January 2014 through February 2021). Study groups were defined by mechanism: penetrating vs blunt. Subgroup analysis was performed of patients arriving with vital signs. Univariable/multivariable analyses compared injuries and outcomes.

RESULTS

Seven hundred fifty-nine patients underwent REBOA: 152 (20%) penetrating and 607 (80%) blunt. Patients undergoing penetrating REBOA were less severely injured (injury severity score 25 vs 34; p < 0.001). The most common hemorrhage source was abdominal in penetrating REBOA (79%) and pelvic in blunt REBOA (31%; p = 0.002). Penetrating REBOA was more likely to occur in the operating room (36% vs 17%) and less likely in the emergency department (63% vs 81%; p < 0.001). Penetrating REBOA used more zone I balloon deployment (76% vs 64%) and less zone III (19% vs 34%; p = 0.001). Improved or stabilized hemodynamics were less frequent after penetrating REBOA (41% vs 62%, p < 0.001; 23% vs 41%, p < 0.001). On subgroup analysis of patients arriving alive, improvement or stabilization in hemodynamics was similar between groups (87% vs 86%, p = 0.388; 77% vs 72%, p = 0.273). Penetrating REBOA was not independently associated with mortality (odds ratio 1.253; p = 0.776).

CONCLUSIONS

Despite lower injury severity, REBOA was significantly less likely to improve or stabilize hemodynamics after penetrating trauma. Among patients arriving alive, however, outcomes were comparable, suggesting that penetrating REBOA may be most beneficial among patients with vital signs. Because hemorrhage source, catheter insertion setting, and deployment zone varied significantly between groups, existing blunt REBOA data may not be appropriately extrapolated to penetrating trauma. Further study of REBOA as a means of aortic occlusion in penetrating trauma is needed.

Damage control surgery for thoracic outlet vascular injuries: the new resuscitative median sternotomy plus REBOA

Thoracic vascular trauma is associated with high mortality and is the second most common cause of death in patients with trauma following head injuries. Less than 25% of patients with a thoracic vascular injury arrive alive to the hospital and more than 50% die within the first 24 hours. Thoracic trauma with the involvement of the great vessels is a surgical challenge due to the complex and restricted anatomy of these structures and its association with adjacent organ damage. This article aims to delineate the experience obtained in the surgical management of thoracic vascular injuries via the creation of a practical algorithm that includes basic principles of damage control surgery. We have been able to show that the early application of a resuscitative median sternotomy together with a zone 1 resuscitative endovascular balloon occlusion of the aorta (REBOA) in hemodynamically unstable patients with thoracic outlet vascular injuries improves survival by providing rapid stabilization of central aortic pressure and serving as a bridge to hemorrhage control. Damage control surgery principles should also be implemented when indicated, followed by definitive repair once the correction of the lethal diamond has been achieved. To this end, we have developed a six-step management algorithm that illustrates the surgical care of patients with thoracic outlet vascular injuries according to the American Association of the Surgery of Trauma (AAST) classification.

Damage control in penetrating carotid artery trauma: changing a 100-year paradigm

Carotid artery trauma carries a high risk of neurological sequelae and death. Surgical management of these injuries has been controversial because it entails deciding between repair or ligation of the vessel, for which there is still no true consensus either way. This article proposes a new management strategy for carotid artery injuries based on the principles of damage control surgery which include endovascular and/or traditional open repair techniques. The decision to operate immediately or to perform further imaging studies will depend on the patient's hemodynamic status. If the patient presents with massive bleeding, an expanding neck hematoma or refractory hypovolemic shock, urgent surgical intervention is indicated. An altered mental status upon arrival is a potentially poor prognosis marker and should be taken into account in the therapeutic decision-making. We describe a step-by-step algorithmic approach to these injuries, including open and endovascular techniques. In addition, conservative non-operative management has also been included as a potentially viable strategy in selected patients, which avoids unnecessary surgery in many cases.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis

Background

Multiple studies regarding the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in patients with non-compressible torso injuries and uncontrolled haemorrhagic shock were recently published. To date, the clinical evidence of the efficacy of REBOA is still debated. We aimed to conduct a systematic review assessing the clinical efficacy and safety of REBOA in patients with major trauma and uncontrolled haemorrhagic shock.

Methods

We systematically searched MEDLINE (PubMed), EMBASE and CENTRAL up to June 2020. All randomized controlled trials and observational studies that investigated the use of REBOA compared to resuscitative thoracotomy (RT) with/without REBOA or no-REBOA were eligible.

We followed the PRISMA and MOOSE guidelines. Two authors independently extracted data and appraised the risk of bias of included studies. Effect sizes were pooled in a meta-analysis using random-effects models. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Primary outcomes were mortality, volume of infused blood components, health-related quality of life, time to haemorrhage control and any adverse effects. Secondary outcomes were improvement in haemodynamic status and failure/success of REBOA technique.

Results

We included 11 studies (5866 participants) ranging from fair to good quality. REBOA was associated with lower mortality when compared to RT (aOR 0.38; 95% CI 0.20–0.74), whereas no difference was observed when REBOA was compared to no-REBOA (aOR 1.40; 95% CI 0.79–2.46). No significant difference in health-related quality of life between REBOA and RT (p = 0.766). The most commonly reported complications were amputation, haematoma and pseudoaneurysm. Sparse data and heterogeneity of reporting for all other outcomes prevented any estimate.

Conclusions

Our findings on overall mortality suggest a positive effect of REBOA among non-compressible torso injuries when compared to RT but no differences compared to no-REBOA. Variability in indications and patient characteristics prevents any conclusion deserving further investigation. REBOA should be promoted in specific training programs in an experimental setting in order to test its effectiveness and a randomized trial should be planned.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-021-00386-9.

Is resuscitative endovascular balloon occlusion of the aorta for computed tomography diagnosis feasible or not? A Japanese single-center, retrospective, observational study

BACKGROUND

Advances in medical equipment have resulted in changes in the management of severe trauma. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in this scenario is still unclear. This study aimed to evaluate the usage of REBOA and utility of computed tomography (CT) in the setting of aortic occlusion in our current trauma management.

METHODS

This Japanese single-tertiary center, retrospective, and observational study analyzed 77 patients who experienced severe trauma and persistent hypotension between October 2014 and March 2020.

RESULTS

All patients required urgent hemostasis. Twenty patients underwent REBOA, 11 underwent open aortic cross-clamping, and 46 did not undergo aortic occlusion. Among patients who underwent aortic occlusion, 19 patients underwent prehemostasis CT, and 7 patients underwent operative exploration without prehemostasis CT for identifying active bleeding sites. The 24-hour and 28-day survival rates in patients who underwent CT were not inferior to those in patients who did not undergo CT (24-hour survival rate, 84.2% vs. 57.1%; 28-day survival rate, 47.4% vs. 28.6%). Moreover, the patients who underwent CT had less discordance between primary hemostasis site and main bleeding site compared with patients who did not undergo CT (5% vs. 71.4%, p = 0.001). In the patients who underwent prehemostasis CT, REBOA was the most common approach of aortic occlusion. Most of the bleeding control sites were located in the retroperitoneal space. There were many patients who underwent interventional radiology for hemostasis.

CONCLUSION

In a limited number of patients whose cardiac arrests were imminent and in whom no active bleeding sites could be clearly identified without CT findings, REBOA for CT diagnosis may be effective; however, further investigations are needed.

LEVEL OF EVIDENCE

Therapeutic/care management study, level V.

Damage control in the emergency department, a bridge to life

Patients with hemodynamic instability have a sustained systolic blood pressure less or equal to 90 mmHg, a heart rate greater or equal to 120 beats per minute and an acute compromise of the ventilation/oxygenation ratio and/or an altered state of consciousness upon admission. These patients have higher mortality rates due to massive hemorrhage, airway injury and/or impaired ventilation. Damage control resuscitation is a systematic approach that aims to limit physiologic deterioration through strategies that address the physiologic debt of trauma. This article aims to describe the experience earned by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia in the management of the severely injured trauma patient in the emergency department following the basic principles of damage control surgery. Since bleeding is the main cause of death, the management of the severely injured trauma patient in the emergency department requires a multidisciplinary team that performs damage control maneuvers aimed at rapidly controlling bleeding, hemostatic resuscitation, and/or prompt transfer to the operating room, if required.

Damage control surgery in lung trauma

Damage control techniques applied to the management of thoracic injuries have evolved over the last 15 years. Despite the limited number of publications, information is sufficient to scatter some fears and establish management principles. The severity of the anatomical injury justifies the procedure of damage control in only few selected cases. In most cases, the magnitude of the physiological derangement and the presence of other sources of bleeding within the thoracic cavity or in other body compartments constitutes the indication for the abbreviated procedure. The classification of lung injuries as peripheral, transfixing, and central or multiple, provides a guideline for the transient bleeding control and for the definitive management of the injury: pneumorraphy, wedge resection, tractotomy or anatomical resection, respectively.

Identification of specific patterns such as the need for resuscitative thoracotomy, or aortic occlusion, the existence of massive hemothorax, a central lung injury, a tracheobronchial injury, a major vascular injury, multiple bleeding sites as well as the recognition of hypothermia, acidosis or coagulopathy, constitute the indication for a damage control thoracotomy. In these cases, the surgeon executes an abbreviated procedure with packing of the bleeding surfaces, primary management with packing of some selected peripheral or transfixing lung injuries, and the postponement of lung resection, clamping of the pulmonary hilum in the most selective way possible. The abbreviation of the thoracotomy closure is achieved by suturing the skin over the wound packed, or by installing a vacuum system. The management of the patient in the intensive care unit will allow identification of those who require urgent reintervention and the correction of the physiological derangement in the remaining patients for their scheduled reintervention and definitive management.

Damage control surgery for splenic trauma: "preserve an organ - preserve a life"

The spleen is one of the most commonly injured solid organs of the abdominal cavity and an early diagnosis can reduce the associated mortality. Over the past couple of decades, management of splenic injuries has evolved to a prefered non-operative approach even in severely injured cases. However, the optimal surgical management of splenic trauma in severely injured patients remains controversial. This article aims to present an algorithm for the management of splenic trauma in severely injured patients, that includes basic principles of damage control surgery and is based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. The choice between a conservative or a surgical approach depends on the hemodynamic status of the patient. In hemodynamically stable patients, a computed tomography angiogram should be performed to determine if non-operative management is feasible and if angioembolization is required. While hemodynamically unstable patients should be transferred immediately to the operating room for damage control surgery, which includes splenic packing and placement of a negative pressure dressing, followed by angiography with embolization of any ongoing arterial bleeding. It is our recommendation that both damage control principles and emerging endovascular technologies should be applied to achieve splenic salvage when possible. However, if surgical bleeding persists a splenectomy may be required as a definitive lifesaving maneuver.

Hemodynamically unstable non-compressible penetrating torso trauma: a practical surgical approach

Penetrating torso trauma is the second leading cause of death following head injury. Traffic accidents, falls and overall blunt trauma are the most common mechanism of injuries in developed countries; whereas, penetrating trauma which includes gunshot and stabs wounds is more prevalent in developing countries due to ongoing violence and social unrest. Penetrating chest and abdominal trauma have high mortality rates at the scene of the incident when important structures such as the heart, great vessels, or liver are involved. Current controversies surround the optimal surgical approach of these cases including the use of an endovascular device such as the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and the timing of additional imaging aids. This article aims to shed light on this subject based on the experience earned during the past 30 years in trauma critical care management of the severely injured patient. We have found that prioritizing the fact that the patient is hemodynamically unstable and obtaining early open or endovascular occlusion of the aorta to gain ground on avoiding the development of the lethal diamond is of utmost importance. Damage control surgery starts with choosing the right surgery of the right cavity in the right patient. For this purpose, we present a practical and simple guide on how to perform the surgical approach to penetrating torso trauma in a hemodynamically unstable patient.

Use of REBOA in the universe of magical realism: a real-world review

While reading the novella “Chronicle of a Death Foretold” by the Colombian Nobel Laureate Gabriel García-Marquez, we were surprised to realize that the injuries sustained by the main character could have been successfully treated had he received modern trauma care in which REBOA may have been considered. This is a discussion of Mr. Nasar's murder to explore whether he could have been saved by deploying REBOA as a surgical adjunct to bleeding control and resuscitation. In reading García-Marquez's novel we noted the events that unfolded at the time of Santiago Nasar's murder. To contextualize the claim that Mr. Nasar could have survived, had his injuries been treated with REBOA, we explored and illustrated what could have done differently and why. On the day of his death, Mr. Nasar sustained multiple penetrating stab wounds. Although he received multiple stab wounds to his torso, the book describes seven potentially fatal injuries, resulting in hollow viscus, solid viscus, and major vascular injuries. We provided a practical description of the clinical and surgical management algorithm we would have followed in Mr. Nasar's case. This algorithm included the REBOA deployment for hemorrhage control and resuscitation. The use of REBOA as part of the surgical procedures performed could have saved Mr. Nasar's life. Based on our current knowledge about REBOA in trauma surgery, we claim that its use, coupled with appropriate surgical care for hemorrhage control, could have saved Santiago Nasar's life, and thus prevent a death foretold.

Buscando el punto crítico de presión arterial sistólica para la oclusión endovascular de la aorta: Análisis mundial de los registros REBOA

Introducción. La presión arterial sistólica puede ser un factor determinante para la toma de decisiones en el manejo de pacientes con trauma severo y hemorragia no compresible del torso. El objetivo de este trabajo fue determinar el punto óptimo de presión arterial sistólica previo a la oclusión endovascular de aorta asociado con la mortalidad a las 24 horas. Métodos. Se realizó un análisis combinado de dos bases de datos de registro de REBOA, ABO-Trauma Registry y AAST-AORTA, que incluye pacientes de Norte América, Suramérica, Europa, Asia y África. Pacientes sin efecto hemodinámico con el uso del REBOA fueron excluidos. Se describieron las características demográficas, clínicas y de la colocación del REBOA en los pacientes que fallecieron en las primeras 24 horas. Se analizó la asociación entre la presión arterial sistólica previa a la oclusión aortica y la mortalidad a través de modelos de regresión logística y se evaluó el poder predictivo de la presión arterial sistólica en un intervalo entre 60 y 90 mmHg. Resultados. Fueron identificados 871 registros, pero solo 693 pacientes cumplieron con los criterios de inclusión. El trauma cerrado se presentó en el 67,2 % de los pacientes y la severidad del trauma tuvo una mediana de ISS de 34 (RIQ: 25-45). La mediana de la presión arterial sistólica previa al REBOA fue de 61 mmHg (RIQ: 46-80). La mortalidad a las 24 horas fue del 34,6 %. La asociación entre la presión arterial sistólica pre-oclusión de la aorta y la mortalidad a las 24 horas tiene una capacidad predictiva de acuerdo con el área bajo la curva ROC para trauma cerrado de 0,64 (IC95% 0,59-0,70) y para trauma penetrante de 0,61 (IC95% 0,53-0,69). Se identificó que la presión arterial sistólica de 70 mmHg se asocia con un aumento por encima del 25 % de la mortalidad a las 24 horas. Discusión. La presión arterial sistólica de 70 mmHg en pacientes con trauma severo y hemorragia no compresible puede ser el punto crítico para la oclusión endovascular de aorta para mejorar la supervivencia de los pacientes, sin importar el mecanismo de trauma. Sin embargo, la presión arterial sistólica debe complementarse con otros factores clínicos para tomar la decisión oportuna.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries

Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

The critical threshold value of systolic blood pressure for aortic occlusion in trauma patients in profound hemorrhagic shock

BACKGROUND

This study aimed to determine the critical threshold of systolic blood pressure (SBP) for aortic occlusion (AO) in severely injured patients with profound hemorrhagic shock.

METHODS

All adult patients (>15 years) undergoing AO via resuscitative endovascular balloon occlusion of the aorta (REBOA) or thoracotomy with aortic cross clamping (TACC) between 2014 and 2018 at level I trauma center were included. Patients who required cardiopulmonary resuscitation in the prehospital setting were excluded. A logistic regression analysis based on mechanism of injury, age, Injury Severity Score, REBOA/TACC, and SBP on admission was done.

RESULTS

A total of 107 patients underwent AO. In 57, TACC was performed, and in 50, REBOA was performed. Sixty patients who underwent AO developed traumatic cardiac arrest (TCA), and 47 did not (no TCA). Penetrating trauma was more prevalent in the TCA group (TCA, 90% vs. no TCA, 74%; p < 0.05) but did not modify 24-hour mortality (odds ratio, 0.51; 95% confidence interval, 0.13-2.00; p = 0.337). Overall, 24-hour mortality was 47% (50) and 52% (56) for 28-day mortality. When the SBP reached 60 mm Hg, the predicted mortality at 24 hours was more than 50% and a SBP lower than 70 mm Hg was also associated with an increased of probability of cardiac arrest.

CONCLUSION

Systolic blood pressure of 60 mm Hg appears to be the optimal value upon which AO must be performed immediately to prevent the probability of death (>50%). However, values of SBP less than 70 mm Hg also increase the probability of cardiac arrest.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): update and insights into current practices and future directions for research and implementation

Background

In this review, we assess the state of Resuscitative Endovascular Occlusion of the Aorta (REBOA) today with respect to out-of-hospital (OOH) vs. inhospital (H) use in blunt and penetrating trauma, as well as discuss areas of promising research that may be key in further advancement of REBOA applications.

Methods

To analyze the trends in REBOA use, we conducted a review of the literature and identified articles with human or animal data that fit the respective inclusion and exclusion criteria. In separate tables, we compiled data extracted from selected articles in categories including injury type, zone and duration of REBOA, setting in which REBOA was performed, sample size, age, sex and outcome. Based on these tables as well as more detailed review of some key cases of REBOA usage, we assessed the current state of REBOA as well as coagulation and histological disturbances associated with its usage. All statistical tests were 2-sided using an alpha=0.05 for significance. Analysis was done using SAS 9.5 (Cary, NC). Tests for significance was done with a t-test for continuous data and a Chi Square Test for categorical data.

Results

In a total of 44 cases performed outside of a hospital in both military and civilian settings, the overall survival was found to be 88.6%, significantly higher than the 50.4% survival calculated from 1,807 cases of REBOA performed within a hospital (p<.0001). We observe from human data a propensity to use Zone I in penetrating trauma and Zone III in blunt injuries. We observe lower final metabolic markers in animal studies with shorter REBOA time and longer follow-up times.

Conclusions

Further research related to human use of REBOA must be focused on earlier initiation of REBOA after injury which may depend on development of rapid vascular access devices and techniques more so than on any new improvements in REBOA. Future animal studies should provide detailed multisystem organ assessment to accurately define organ injury and metabolic burden associated with REBOA application. Overall, animal studies must involve realistic models of injury with severe clinical scenarios approximating human trauma and exsanguination, especially with long-term follow-up after injury.

Damage control resuscitation: REBOA as the new fourth pillar

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.

Prehospital Damage Control: The Management of Volume, Temperature… and Bleeding!

Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the “Stop the Bleed” initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the “Stop the Bleed” initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.

Damage control surgery: a constant evolution

The story of trauma resuscitation is similar to that of many other advances in medicine: described, forgotten, reinvented, ridiculed, and finally accepted. Even after acceptance, the concepts go through periods of neglect and indifference before they are tried and enhanced, till the next advance. Damage control, a strategy for management of critically injured or ill patients, is a prime example of this phenomenon. It reminds us of the famous words of Oliver Goldsmith in 1761: “for he who fights and runs away, will live to fight another day, but he who is in battle slain, will never rise and fight again”. Damage control was based on the recognition of the lethal triad of hypothermia, acidosis, and a coagulopathy resulting from massive blood loss, large-volume resuscitation and ischemia-reperfusion. It was an approach that J. Hogarth Pringle from Glasgow, Scotland, suggested in 1908 with his principles of compression and hepatic packing for control of venous hemorrhage from the injured liver: temporary, expeditious and effective. Packing, however, was rarely utilized during World War II and the Vietnam War because of the presumed risk of rebleeding with removal of the packs. The ever-difficult challenge of “non-surgical bleeding” from a coagulopathy due to massive hepatic injuries did, eventually, lead to a resurrection of the concept of perihepatic packing in the 1980s in civilian centers and became one of the initial steps in damage control for patients with severe and/or multiple intra-abdominal injuries.

Damage Control in Penetrating Liver Trauma: Fear of the Unknown

The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.

REBOA as a New Damage Control Component in Hemodynamically Unstable Noncompressible Torso Hemorrhage Patients

Noncompressible torso hemorrhage is one of the leading causes of preventable death worldwide. An efficient and appropriate evaluation of the trauma patient with ongoing hemorrhage is essential to avoid the development of the lethal diamond (hypothermia, coagulopathy, hypocalcemia, and acidosis). Currently, the initial management strategies include permissive hypotension, hemostatic resuscitation, and damage control surgery. However, recent advances in technology have opened the doors to a wide variety of endovascular techniques that achieve these goals with minimal morbidity and limited access. An example of such advances has been the introduction of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which has received great interest among trauma surgeons around the world due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology. This article aims to describe the experience earned in the use of REBOA in noncompressible torso hemorrhage patients. Our results show that REBOA can be used as a new component in the damage control resuscitation of the severely injured trauma patient. To this end, we propose two new deployment algorithms for hemodynamically unstable noncompressible torso hemorrhage patients: one for blunt and another for penetrating trauma. We acknowledge that REBOA has its limitations, which include a steep learning curve, its inherent cost and availability. Although to reach the best outcomes with this new technology, it must be used in the right way, by the right surgeon with the right training and to the right patient.