Evaluation and Management of Hemodynamically Unstable Abdominal Penetrating/Blunt Trauma

Unstable Patient

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  Persistent hypotension: Systolic blood pressure (SBP) <90 mm Hg

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  Transient or no response in blood pressure with crystalloid infusion

Initial Management

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  Assessment of the airway

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    Secure a definitive airway.

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    Protect the cervical spine.

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  Assessment of breathing and management as indicated

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  Assessment of circulation

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    IV access, central venous access if possible

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    Arterial line if possible

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    Resuscitation with crystalloid solution infusion

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    Initiation of massive transfusion protocol

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  Assessment for the neurological deficit

Definition of REBOA

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  Involves placement of an endovascular balloon in the aorta to control hemorrhage

Zones of REBOA

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  The aorta is divided into three separate zones for the purposes of REBOA balloon deployment.

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    Zone I

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      Extends from the origin of the left subclavian artery to the celiac artery

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    Zone II

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      Extends from the celiac artery to the most caudal renal artery

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      Approximately 3 cm long

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      REBOA balloon not recommended in this zone

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    Zone III

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      Extends from the most caudal renal artery to the aortic bifurcation

Indications for REBOA Balloon in Unstable Abdominal Trauma

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  Blunt abdominal trauma

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    Zone I REBOA

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      Positive Focused Assessment with Sonography in Trauma (FAST) suggestive for intraabdominal hemorrhage

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      Negative FAST with negative pelvic x-ray for fractures

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    Zone III REBOA

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      Negative FAST with positive pelvic x-ray for fractures

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  Penetrating abdominal trauma

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    Zone I REBOA

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      Hemodynamically unstable patient

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    Zone III REBOA

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      Pelvic or groin injury with uncontrolled hemorrhage

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      Junctional vascular injury (iliac or common femoral vessels)

Contraindications for REBOA

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  High clinical/radiological suspicion of thoracic aortic injury

Post-REBOA Placement

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  After Zone I REBOA placement, proceed for an emergent exploratory laparotomy, if possible, within 15 minutes.

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  After Zone III REBOA placement, proceed for an emergent exploratory laparotomy, or preperitoneal packing, or an angioembolization.

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  Compared to Zone I REBOA, Zone III REBOA is tolerated for a slightly longer period.

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  Partial inflation of the balloon at either location may prolong the duration of REBOA to a maximum of 60 minutes.

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  The balloon should be deflated as soon as possible.

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  The catheter and sheath should be removed as soon as possible.

Complications of REBOA

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  Complication from femoral arterial access

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    Hematoma at the access site

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    Arterial disruption

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    Arterial dissection

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    Pseudoaneurysm

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    Thromboembolism

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    Extremity ischemia

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  Aortoiliac injury

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    Intimal injury

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    Thrombosis

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    Dissection

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    Arterial rupture

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    Limb loss

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  Rupture of the balloon due to overinflation

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  Prolonged aortic occlusion

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    Spinal cord injury due to prolonged ischemia

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    Cardiac events

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    Renal complications