Should Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) be used routinely in patients with hypotension due to blunt trauma with suspected unstable pelvic fracture?

From the Guidelines

REBOA should not be used routinely in patients with hypotension due to blunt trauma with suspected unstable pelvic fracture, but rather reserved for cases with profound hemorrhagic shock where initial resuscitation efforts and immediate surgical intervention or angioembolization are not feasible. The decision to use REBOA should be made by experienced trauma teams with proper training in the technique, appropriate equipment, and clear protocols for patient selection, as highlighted in the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.

Key Considerations

• The use of REBOA is associated with significant risks, including limb ischemia, organ failure, and procedural complications, as noted in the guideline 1.
• Alternative interventions such as pelvic binders, rapid blood product administration, and expedited transfer to definitive care (surgical fixation or angioembolization) remain the first-line approaches for most patients with unstable pelvic fractures, as discussed in the European guideline 1 and further elaborated in the rationale section of the guideline 1.
• The evidence demonstrating that REBOA improves survival is conflicting, and quality evidence to support the clinical use of REBOA is lacking, as concluded in the systematic review and meta-analysis 1.

Clinical Approach

• In patients with suspected unstable pelvic fractures, external emergency stabilization using a non-invasive pelvic binder, invasive external fixation, or C-clamp should be employed, depending on the individual injury pattern, as recommended in the guideline 1.
• Ongoing bleeding after external emergency stabilization can be managed using either temporary retroperitoneal packing combined with laparotomy when needed and/or angioembolization, as discussed in the guideline 1.
• REBOA may serve as a bridge between hemodynamic collapse and definitive bleeding control in selected patients, but its use should be carefully considered due to the potential risks and lack of strong evidence supporting its routine use, as noted in the guideline 1.

Recommendation

The use of REBOA should be individualized, considering the patient's specific clinical scenario, the availability of resources, and the potential risks and benefits, as emphasized in the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.

From the Research

Use of REBOA in Patients with Hypotension due to Blunt Trauma

• The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in patients with hypotension due to blunt trauma with suspected unstable pelvic fracture is a topic of ongoing research and debate 2, 3, 4.
• Studies have shown that REBOA can be a valuable adjunct in hemostatic non-responders, but its definitive role in Damage Control Resuscitation (DCR) is not yet clearly established 2.
• A study comparing REBOA and pre-peritoneal packing (PP) in patients with pelvic fractures found that REBOA was associated with improved outcomes, including lower mortality and faster times to laparotomy and angioembolization 3.
• Another study discussed the management of pelvic trauma, highlighting the importance of a multidisciplinary approach and the use of various modalities, including REBOA, to achieve hemorrhage control 4.

Comparison with Other Treatment Options

• REBOA has been compared to other treatment options, such as pre-peritoneal packing (PP) and angiographic intervention, with varying results 3, 5, 6.
• A study on pre-peritoneal pelvic packing found that it can be a rapid and effective method for controlling pelvic fracture-related hemorrhage, reducing the need for emergent angiography and lowering mortality 6.
• The choice of treatment modality may depend on various factors, including the patient's condition, the severity of the injury, and the availability of resources 2, 4.

Current Recommendations

• The current evidence suggests that REBOA can be a useful tool in the management of patients with hypotension due to blunt trauma with suspected unstable pelvic fracture, but its use should be considered on a case-by-case basis 2, 3, 4.
• Further research is needed to define the optimal patient who will benefit from REBOA and to establish clear guidelines for its use in this context 3.