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Open Access

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

Amelia Walling Maiga, Rishi Kundi, Jonathan James Morrison, Chance Spalding, Juan Duchesne, John Hunt, Jonathan Nguyen, Elizabeth Benjamin, Ernest E Moore, Ryan Lawless, Andrew Beckett, Rachel Russo, Bradley M Dennis
DOI: 10.1136/tsaco-2022-000984 Published 23 December 2022
Amelia Walling Maiga
1Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Rishi Kundi
2R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
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Jonathan James Morrison
2R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
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Chance Spalding
3Grant Medical Center, Columbus, Ohio, USA
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Juan Duchesne
4Tulane University School of Medicine, New Orleans, Louisiana, USA
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John Hunt
5University Medical Center New Orleans, New Orleans, Louisiana, USA
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Jonathan Nguyen
6Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
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Elizabeth Benjamin
7Emory University, Atlanta, Georgia, USA
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Ernest E Moore
8Denver Health Medical Center, Denver, Colorado, USA
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Ryan Lawless
8Denver Health Medical Center, Denver, Colorado, USA
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Andrew Beckett
9St Michael's Hospital, Toronto, Ontario, Canada
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Rachel Russo
10University of California Davis Medical Center, Sacramento, California, USA
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Bradley M Dennis
1Vanderbilt University Medical Center, Nashville, Tennessee, USA
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  • Figure 1
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    Figure 1

    PICAR framework for systematic review of REBOA patient selection clinical practice guidelines. CFA, common femoral artery; PICAR, population, intervention, comparison, attributes, and recommendation characteristics; REBOA, resuscitative endovascular balloon occlusion of the aorta.

  • Figure 2
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    Figure 2

    PRISMA flow sheet. REBOA, resuscitative endovascular balloon occlusion of the aorta.

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    Figure 3

    Consensus and Variability in REBOA Patient Selection Criteria. Gray indicates the inclusion of this detail in the algorithm, white indicates the absence of explicit inclusion, and “X” indicates this detail included as a contraindication. CFA, common femoral artery; NA, not applicable; pREBOA, partial REBOA; REBOA, resuscitative endovascular balloon occlusion of the aorta; SBP, systolic blood pressure.

Tables

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  • Table 1

    Publications presenting algorithms for REBOA patient selection (2015–2022)

    YearFirst author (institution)Data sources citedMethodologyScope limitationsComments on early CFA access?Contraindications to REBOACriteria for REBOA patient selection
    2018Brenner (ACSCOT and ACEP)24YesJoint policy statement based on published data, best evidence, and expert opinionNoneNo
    • None specified.

    • Traumatic life-threatening hemorrhage below the diaphragm in patients in hemorrhagic shock who are unresponsive or transiently responsive to resuscitation.

    • Patients arriving in arrest from injury.

    2019Borger van der Burg (multicenter)7NoDelphi consensus (3 rounds, 43 experts responding)NoneYes
    • Major bleeding in the neck or proximal to the left subclavian artery.

    • Traumatic abdominopelvic hemorrhage.

    • Trauma patients with initial SBP <90 who do not respond to resuscitation.

    • Any trauma victim with ATLS class IV hypovolemic shock.

    2020Glaser (JTS)8YesMilitary guidelinesMilitaryNo
    • Severe blunt chest injury.

    • Profound shock or traumatic arrest due to penetrating neck, chest, or extremity injury.

    • SBP <90 and transient or no response to initial resuscitation in blunt trauma or penetrating abdominal/pelvic/junctional injury.

    • Traumatic arrest (blunt or penetrating) based on injury location and CPR time.

    2020Brenner (UC Riverside and Shock Trauma)22YesNot specifiedTraumatic cardiac arrestYes
    • None specified.

    • Blunt or non-thoracic penetrating injury.

    • Hemorrhage location unknown or below the diaphragm.

    • Consider with hemorrhage location in the thorax in combination with resuscitative thoracotomy.

    2020Ordoñez (Cali, Colombia)16 17YesInstitutional algorithmNoneYes
    • None specified.

    • Non-compressible torso hemorrhage.

    • Blunt or penetrating mechanism.

    • SBP <90 and transient responder to resuscitation.

    2022Inaba (WTA)20YesSociety consensusNoneYes
    • Major thoracic vascular injury.

    • Sustained hypotension refractory to resuscitation.

    2021Johnson (multicenter)25YesConsensus after multicenter observational studyNoneYes
    • Thoracic hemorrhage.

    • SBP <90 and partial or non-responder.

    2021Castellini (Milan, Italy)26YesNot specifiedNoneNo
    • Suspicion of thoracic aorta injury.

    • Hypotensive trauma patients with suspected torso hemorrhage.

    • Non-responders to resuscitation.

    • Positive FAST or positive pelvic X-ray.

    2021Hadley (Denver Health)15YesInstitutional algorithmNoneNo
    • Thoracic hemorrhage.

    • SBP <80 and hemorrhage location.

    • Traumatic arrest with pelvic or extremity hemorrhage.

    2022Nagashima (Japan)27YesNot specifiedNoneYes
    • Near/recent cardiac arrest.

    • Possible aortic injury.

    • Hypotensive partial or non-responder.

    • ACEP, American College of Emergency Physicians; ACSCOT, American College of Surgeons' Committee on Trauma; ATLS, advanced trauma life support; CFA, common femoral artery; CPR, cardiopulmonary resuscitation; FAST, focused assessment with sonography in trauma; JTS, Joint Trauma System; REBOA, resuscitative endovascular balloon occlusion of the aorta; SBP, systolic blood pressure; UC, University of California; WTA, Western Trauma Association.

  • Table 2

    Partial REBOA rollout collaborative institutional algorithms for REBOA patient selection

    InstitutionData sources citedTrigger for early CFA accessContraindications to REBOACriteria for REBOA patient selection
    Ernest E Moore Shock Trauma Center at Denver Health (Denver, Colorado)No
    • SBP <100: 5Fr.

    • SBP <90: 7Fr.

    • SBP <80: REBOA.

    • Active thoracic bleeding.

    • SBP <80 and cavitary triage.

    Grady Memorial Hospital (Atlanta, Georgia)No
    • Concern for truncal hemorrhage.

    • SBP <90, received 2 units of blood product, or transient transponder.

    • Not specified.

    • SBP <90.

    • Transient responder to resuscitation.

    • Non-responder to 2 units of blood.

    • Traumatic cardiac arrest.

    Grant Medical Center (Columbus, Ohio)No
    • SBP <90.

    • Transient responder.

    • Profound, refractory shock.

    • OHCA with ROSC.

    • Not specified.

    • SBP <90 with inadequate response to resuscitation.

    • Profoundly hypotensive.

    • Hypovolemic cardiac arrest and not beyond salvage.

    University of Maryland Shock Trauma Center (Baltimore, Maryland)No
    • None specified.

    • Not specified.

    • Persistently hypotensive or transient responder.

    • Low suspicion for aortic injury.

    • Evidence of vascular continuity from CFA to thoracic aorta.

    • Attending trauma surgeon or intensivist discretion.

    St Michael’s Hospital (Toronto, Ontario)Yes
    • Pelvic fracture.

    • Positive FAST and SBP <90.

    • Not specified.

    • Traumatic arrest for abdominal/pelvic/junctional hemorrhage provided reversible cause suspected.

    • SBP <90 and transient or non-responder with positive abdominal FAST or pelvic X-ray (blunt) or abdominal/pelvic/junctional injury (penetrating).

    University Medical Center New Orleans (New Orleans, Louisiana)Yes
    • SBP <90 and partial or non-responder.

    • Blunt: possible aortic injury on CXR.

    • Penetrating: possible supradiaphragmatic or cardiac injury.

    • Blunt: SBP <90 and partial or non-responder.

    • Penetrating: SBP <90 and truncal/lower extremity injury (in OR).

    • In OR: SBP <90, transient responder, profound refractory shock, or prehospital CPR with ROSC.

    Vanderbilt University Medical Center (Nashville, Tennessee)No
    • SBP <80 with a pulse.

    • Thoracic aortic injury.

    • Transient or non-responder.

    • CFA, common femoral artery; CPR, cardiopulmonary resuscitation; CXR, chest X-ray; FAST, focused assessment with sonography in trauma; Fr, French; OHCA, out of hospital cardiac arrest; OR, operating room; REBOA, resuscitative endovascular balloon occlusion of the aorta; ROSC, return of spontaneous circulation; SBP, systolic blood pressure.

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Systematic review to evaluate algorithms for REBOA use in trauma and identify a consensus for patient selection
Amelia Walling Maiga, Rishi Kundi, Jonathan James Morrison, Chance Spalding, Juan Duchesne, John Hunt, Jonathan Nguyen, Elizabeth Benjamin, Ernest E Moore, Ryan Lawless, Andrew Beckett, Rachel Russo, Bradley M Dennis
Trauma Surg Acute Care Open Dec 2022, 7 (1) e000984; DOI: 10.1136/tsaco-2022-000984

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Systematic review to evaluate algorithms for REBOA use in trauma and identify a consensus for patient selection
Amelia Walling Maiga, Rishi Kundi, Jonathan James Morrison, Chance Spalding, Juan Duchesne, John Hunt, Jonathan Nguyen, Elizabeth Benjamin, Ernest E Moore, Ryan Lawless, Andrew Beckett, Rachel Russo, Bradley M Dennis
Trauma Surg Acute Care Open Dec 2022, 7 (1) e000984; DOI: 10.1136/tsaco-2022-000984
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Systematic review to evaluate algorithms for REBOA use in trauma and identify a consensus for patient selection
Amelia Walling Maiga, Rishi Kundi, Jonathan James Morrison, Chance Spalding, Juan Duchesne, John Hunt, Jonathan Nguyen, Elizabeth Benjamin, Ernest E Moore, Ryan Lawless, Andrew Beckett, Rachel Russo, Bradley M Dennis
Trauma Surgery & Acute Care Open Dec 2022, 7 (1) e000984; DOI: 10.1136/tsaco-2022-000984
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