Long Brit, Hafen Lee, Koyfman Alex, Gottlieb Michael
Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas.
Department of General Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas.
J Emerg Med. 2019 Jun;56(6):687-697. doi: 10.1016/j.jemermed.2019.03.030. Epub 2019 Apr 19.
Non-compressible torso hemorrhage (NCTH) is difficult to control and associated with significant mortality. Resuscitative endovascular balloon occlusion of the aorta (REBOA) utilizes an infra-diaphragmatic approach to control NCTH and is less invasive than resuscitative thoracotomy (RT). This article highlights the evidence for REBOA and provides an overview of the indications, procedural steps, and complications in adults for emergency clinicians.
Traumatic hemorrhage can be life threatening. Patients in extremis, whether from NCTH or exsanguination from other sites, may require RT with aortic cross-clamping. REBOA offers another avenue for proximal hemorrhage control and can be completed by emergency clinicians. The American College of Surgeons Committee on Trauma and the American College of Emergency Physicians recently released a joint statement detailing the indications for REBOA in adults. The evidence behind its use remains controversial, with significant heterogeneity among studies. Most studies demonstrate improved blood pressure without a significant improvement in mortality. Procedural steps include arterial access (most commonly the common femoral artery), positioning the initial sheath, balloon preparation and positioning, balloon inflation, securing the balloon/sheath, subsequent hemorrhage control, balloon deflation, and balloon/sheath removal. Several major complications can occur with REBOA placement. Future studies should evaluate training protocols, the role of simulation, and which target populations would benefit most from REBOA.
REBOA can provide proximal hemorrhage control and can be performed by emergency clinicians. This article evaluates the evidence, indications, procedure, and complications for emergency clinicians.
不可压缩性躯干出血（NCTH）难以控制，且死亡率高。复苏性血管内主动脉球囊阻断术（REBOA）采用膈下途径控制NCTH，比复苏性开胸手术（RT）侵入性小。本文重点介绍了REBOA的相关证据，并为急诊临床医生概述了成人患者的适应证、操作步骤及并发症。
创伤性出血可危及生命。处于极度危险状态的患者，无论是因NCTH还是其他部位失血过多，可能都需要进行主动脉交叉钳夹的RT手术。REBOA为近端出血控制提供了另一种途径，急诊临床医生即可完成操作。美国外科医师学会创伤委员会和美国急诊医师学会最近发表了一份联合声明，详细说明了成人患者使用REBOA的适应证。其使用背后的证据仍存在争议，各研究之间存在显著异质性。大多数研究表明，血压有所改善，但死亡率并无显著改善。操作步骤包括动脉穿刺（最常用股总动脉）、放置初始鞘管、球囊准备与放置、球囊充气、固定球囊/鞘管、后续出血控制、球囊放气以及移除球囊/鞘管。放置REBOA可能会出现几种主要并发症。未来的研究应评估培训方案、模拟的作用以及哪些目标人群将从REBOA中获益最大。
REBOA可实现近端出血控制，且急诊临床医生即可操作。本文为急诊临床医生评估了相关证据、适应证、操作及并发症。
