Chapter 74: Catheter-Based Hemorrhage Control

INTRODUCTION

Nine percent of the global annual mortality is from trauma.¹ Trauma is the third leading cause of death in the United States for all ages and the leading cause of death in patients 1 to 44 years of age.¹ Hemorrhage is the leading cause of potentially preventable death, is amenable to interventions, and prevention of hemorrhage can reduce morbidity and mortality.^2,3

Management of the patient with massive hemorrhage should primarily focus on the basics of resuscitation (i.e., airway, breathing, circulation, obtaining large-bore intravenous [IV] access, and activating massive transfusion protocols). Stopping blood loss is critical to patient survival.^4-6 Direct compression at the source of bleeding is usually sufficient. Other options include proximal control with the use of embolization, surgical closure, or tourniquets.^2,4 Hemorrhage can occur from noncompressible or not readily accessible sites (e.g., gastrointestinal tract, intraabdominal, intrathoracic, pelvic, or retroperitoneal).⁷ Limited management options exist for hemodynamically unstable patients due to noncompressible hemorrhage. It may prove dangerous to transport these patients to the Endoscopy Suites, Interventional Radiology (IR), or the Operating Room for definitive hemorrhage control.

Aortic occlusion is one hemorrhage control method that temporarily stops noncompressible torso hemorrhage from injuries that receive blood supply from the subdiaphragmatic aorta. Aortic occlusion improves hemostasis, preserves coronary and cerebral perfusion, and can improve hemodynamics enough to allow for definitive hemorrhage control by embolization, endoscopy, or surgical repair.^8-10 Aortic occlusion may allow more time for induction of anesthesia, intubation, initiation of positive-pressure ventilation, and operative planning.^11-16

Emergency Physicians achieved aortic occlusion traditionally through a thoracotomy (Chapter 54) and supradiaphragmatic clamping of the thoracic aorta (Chapter 58).^17,18 Resuscitative endovascular occlusion of the aorta (REBOA) is a less invasive method of aortic occlusion made possible by advancements in endovascular technology.^17-20 Japan has incorporated catheter-based hemorrhage control in the treatment of solid organ and pelvic injuries. The published data from Japan’s use of REBOA are limited and largely retrospective. The conclusions based on the Japanese data differ on REBOA safety and effectiveness.^21-24 A systematic review from data obtained in the United Kingdom showed benefits with REBOA utilization in the prehospital setting.²⁵

Success with REBOA has been shown in animal models of intraabdominal, pelvic, and uncontrolled junctional (i.e., buttocks, extremity trauma not amenable to tourniquet use, gluteal, groin, and perineum) hemorrhage.^9,13,26,27 Case reports and series support its use in hemorrhagic shock from nontraumatic etiologies of bleeding (e.g., during repair of abdominal aortic aneurysm, ectopic pregnancy, massive hemorrhage after hysterectomy, postpartum hemorrhage, and upper gastrointestinal bleeding).^16,28-32 Clinical studies in trauma patients have shown similar promise for hemorrhage control.^12,33 The largest prospective trial to evaluate aortic occlusion in the United States for trauma patients showed that REBOA resulted in hemodynamic improvement in 67% of ...