A bit concerning for indication creep, no? How often does one see a patient who will benefit from REBOA?
There's a whole lot of questions like that remaining as the hype train keeps building, ha. I'm sure that, especially with the ER-REBOA now available, there will be a surge of interest and with it a lot of these lines being placed in patients that potentially don't need it, but if done safely it's not that different than an arterial-side Cordis, which (in the case of the ER-REBOA, at least) allows for transducing for arterial pressures and to have the balloon ready for inflation if a patient does decompensate suddenly, say for instance when they go to ex-lap and suddenly the tamponade is released on a bleeding liver or spleen or whatever.
In terms of how often it could potentially be used, there's a small body of literature on this, including one study out of Britain that was published this week. Prior civilian studies have demonstrated that non-compressible truncal hemorrhage accounts for 60-70% of deaths following otherwise survivable injuries. In a recent review of the epidemiology of US combat fatalities in Iraq and Afghanistan, Eastridge et al. determined that among the potentially survivable injuries seen on the battlefield before arrival at a medical treatment facility, 91% of deaths were caused by truncal (67.3%), junctional (19.2%), and extremity (13.5%) hemorrhage. A similar percentage (85.5%) was cited in a recent British study.
The
paper just published Barnard and colleagues, suggested that in one year’s worth of trauma patients in England and Wales, there were ~400 patients with an injury pattern and severity that may have benefitted from REBOA. These patients had a high mortality, of almost 33%, which the authors postulate might have been preventable with more prompt control of hemorrhage. More than half of these deaths occurred within 12 hours of hospital arrival, which in the absence of non-survivable TBI (these patients were excluded) may have been due to incomplete hemostasis. The authors estimate that the busier shops receiving trauma in that study would see a potentially-REBOAable patient q 46 days -- and that's in the UK. I would estimate that your average American trauma center sees a bit more in the way of non-compressible truncal hemorrhage.
I'm just now finishing up an educational project on REBOA with one of our anesthesia faculty, so I've been doing a lot of reading on the subject-- sorry for the wall of text. I agree with you that there's concern for indication creep, and that people are going to be trigger-happy to deploy this new toy, but with the smaller lines and U/S guidance in the hands of people used to putting in crash lines it shouldn't be that bad. The question is really just who is this appropriate for, and when/where/who will do the placement, and for that there's not that much evidence to go on. We'll see what come out of Houston, Baltimore, Denver, and the other shops doing a fair bit of this and prospectively gathering data on it.
