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198
4. The liberal use of catheters and the preparedness to abandon any time- consuming
procedure (>5min) in favor of another is accepted and recommended.
5. Changing operator in mid-procedure should also be envisaged when fatigue is
suspected after repeated procedural failures.
6. Balloon occlusion of the internal iliac arteries or abdominal aorta/its branches, as
well as the aorta (REBOA), may be done to either provide the physician enough
time to assess and consult with colleagues or as a temporary adjunct to denitive
surgery in cases of life-threatening hemorrhages prior to laparotomy.
13.6.4 Results: Duration ofProcedure
Integrating a DCIR workow with CT scan and endovascular intervention can
deliver effective diagnoses and treatments to severe exsanguinating injuries. Careful
implementation of DCIR key maneuvers will considerably shorten procedural time
(Fig.13.9). Previous studies demonstrated that the median time from admission to
embolization ranged from 80 min to as much as 5 h [12–14]. However, only
Conductor
Trauma surgeon
Anesthesiologist
Operator
Assistant
Fig. 13.8 Conductor–operator–assistant (COA) triad. The conductor in consultation with the
trauma surgeon orchestrates and guides the operator during the procedure. This eliminates the
operator’s decision-making time as well as the time-consuming maneuvers while performing cath-
eterization. The COA triad optimizes the procedural efciency while minimizing human error and
preventing loss of critical time. The assistant anticipates subsequent maneuvers of the operator by
preparing the appropriate device (guidewire, microcatheter, etc.) and embolization material in a
timely fashion. An anesthesiologist/ICU physician is also present recreating an ICU-like environ-
ment within the angiography-suite
B. D. Lohman and J. Matsumoto
199
angiography within 90min of admission improves survival rates [15]. Angiography
within 60min has a 16% mortality rate, with the rate increasing to 64% when angi-
ography is delayed [16].
At our institution, the implementation of a time-conscious IR on a 10-year old
boy run over by a 20-t truck, resulted in a 30-min embolization time for the right and
left internal, splenic, and left adrenal arteries. Namely, the time for a single arterial
embolization was 7.5min, for a total of four vessels embolized (Fig.13.10).
13.7 Future Trends
13.7.1 Hybrid ER Room
In recent years, the development of hybrid ERs consisting of an angiography suite/
operating room with an integrated CT scan have signicantly reduced the time
between diagnosis and intervention [17]. These improved ergonomic measures
applied alongside a trauma-specicworkow allow the team to efciently perform
rapid bleeding control without patient transfer and improve mortality in severetrauma
[18]. However, without a time conscious IR workow, any hybrid resuscitation
room will not fully exploit its true potential and, therefore, a time rigorous and spe-
cically designed trauma IR protocol for HU patients is a matter of the utmost
importance in order to successfully increase survival rates.
Trauma IR under conventional concept
Trauma IR under time-conscious concept
IR team activation
IR team activation
Primary
survey
CT
Primary
survey
CT
Diagnosis
decision
Direct
transfer
DCIR
Time saved = life saved
Diagnosis
decision
Preparation
Conventional
emergency IR
Fig. 13.9 Conventional IR for trauma versus time conscious IR for trauma. Time conscious IR
guidelines effectively target every step of the management scheme that offers any opportunity for
time optimization. Early activation of the IR trauma team, a shorter CT room time, a trauma-
specic CT imaging evaluation algorithm, and a time rigorous damage control IR are capital
parameters which reduce the wasted procedure time that could be the difference between life and
death in multivessel bleeding HU coagulopathic patients
13 Endovascular Embolization inTrauma andBleeding
200
Fig. 13.10 Case of a 10-year old boy struck and run over by a 20-t truck. A 10-year old boy was
run over by a 20-t truck and was admitted with a systolic blood pressure of 60mmHg. Initial por-
table X-rays (a and b) showed subtle left lower lung contusion (circle), separated symphysis pubis
(circle), and left pelvic fracture (arrow). FAST (focused assessment with sonography for trauma)
was negative. The left internal iliac artery embolization (c) was followed by aortography (d)
revealing splenic (circle) and renal artery extravasation (arrow). Right internal iliac artery emboli-
zation was performed before changing catheters and embolized the splenic artery and the left
adrenal artery (e) thereby sacricing the left adrenal gland and part of the renal artery.
Postembolization aortography did not exhibit any extravasation, conrming successful splenic and
left adrenal embolization (f). A double COA system (two conductors/two operators/two assistants)
angioembolization was implemented and resulted in a four-vessel embolization time of 30min
whereby the patient stabilized, which is the main purpose of DCIR.Postprocedural CT examina-
tion (not shown), revealed additional minor extravasations and a large bowel injury. Additional
angioembolization followed by immediate surgery were performed
B. D. Lohman and J. Matsumoto
201
13.8 Hybrid Trauma Specialist
Additionally, cross-training “hybrid trauma specialists” with combined prociency
in surgery, IR, and emergency medicine, would further improve the trauma care
process with shorter diagnosis and intervention. This concept is a challenge for all
the medical specialties involved. Unlimited interdisciplinary cooperation and
mutual exchange of information are the fundamental principles for successful IR
care and management. Putting aside all interdepartmental contention and develop-
ing periodical cross-educational and training workshops among specialties will
bring about a new specialty: the “trauma hybrid physician” which could potentially
improve future trauma care medicine.
Such strategy may help further expand and redene key concepts and indications
of endovascular techniques within the realm of trauma, as well as nontrauma set-
tings, as a valid adjunct to surgical care.
Recently, the EndoVascular resuscitation and Trauma Management (EVTM)
Society has advocated a multidisciplinary approach, utilizing a hybrid surgery-
endovascular concept to control massive bleedings; this approach has been steadily
growing in popularity among trauma physicians and interventional radiologists
worldwide. EVTM conducts yearly meetings and several workshops in Sweden and
has recently created a North American EVTM branch. This is a clear indication of
the growing awareness that severe trauma HU patients necessitate specic care and
that new methods in trauma care are warranted.
Conclusion
Uncontrolled bleeding patients may be either single- or multiple-vessel bleeders.
CEIR is the commonly utilized method for single-vessel HS noncoagulopathic
patients while TIR can target multiple-vessel HU coagulopathic patients. TIR
Fig. 13.10 (continued)
13 Endovascular Embolization inTrauma andBleeding
202
patients may possibly be death-bound and time is of the essence. The TIR proto-
col consists of early activation of the multidisciplinary trauma team, time-con-
scious CT imaging evaluation followed by damage control IR.Despite the advent
of modern hybrid trauma ER, the successful implementation of such a protocol
may be feasible only with inter-departmental collaboration. Cross-training and
education will create certied “hybrid” cross-certied emergency, trauma and
radiology specialists. Despite its utopic appeal, time conscious trauma IR is
achievable with the right amount of motivation, the right trauma team, and a
strong dedication to saving the dying patient.
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© Springer Nature Switzerland AG 2020
T. Hörer et al. (eds.), Endovascular Resuscitation and Trauma Management,
Hot Topics in Acute Care Surgery and Trauma,
https://doi.org/10.1007/978-3-030-25341-7_14
A. Pierce
Department of Anesthesiology and Perioperative Medicine, University of Alabama at
Birmingham, Birmingham, AL, USA
e-mail: apierce@uabmc.edu
J. O. Jansen (
*)
Division of Acute Care Surgery, University of Alabama at Birmingham,
Birmingham, AL, USA
e-mail: jjansen@uabmc.edu
14
Management oftheUnstable Patient
During EVTM andREBOA
AlbertPierce andJanO.Jansen
14.1 Introduction
Most trauma patients who require Resuscitative Endovascular Balloon Occlusion of
the Aorta (REBOA) will be cardiovascularly “unstable”—whatever that means. The
term is typically used to describe a physiological state characterized by hypoten-
sion, hypoperfusion, and tachycardia, often—but not invariably—brought on by
blood loss. REBOA is used as part of a damage control resuscitation approach,
when blood loss has reached critical levels, to obtain temporary hemorrhage con-
trol, while hemostatic resuscitation is instituted. Understanding the physiological
consequences of REBOA, and the relationship between anesthesia and aortic occlu-
sion, is therefore critically important.
14.2 Understanding thePhysiology ofAortic Occlusion
Supercially, aortic occlusion is an appealing concept: if there is insufcient
circulating blood volume to ll the circulatory system, then reducing the capacity
of the system, and redistributing the remaining blood volume to those organs
most susceptible to hypoperfusion—the brain and the myocardium—makes
sense. However, as always, human physiology is more complex than the concepts
used to describe it. First and foremost, the circulation is not a single pipe, but
206
consists of systemic and pulmonary arterial and venous systems—arguably four
different circulatory systems. The differential effects of REBOA on these circu-
lations are incompletely understood.
The most obvious consequence of REBOA (and the best-researched) is an
increase in systemic (arterial) vascular resistance, but the impact on the other three,
probably mediated through a combination of neurological and endocrine effects, is
harder to predict, especially in the context of severe hypovolemia [1]. The effect of
a sudden increase in afterload on the myocardium which, until this point, had been
struggling with insufcient end-diastolic volume is also not clear, although there is
some evidence to suggest that it may be injurious, or at the very least associated
with troponin release. Lastly, excluding part of the circulation invariably results in
ischemia, which can only be tolerated for a certain period of time. Release of the
occlusion will result not only in dramatic changes to vascular resistance and redis-
tribution of circulating blood volume, but also in the release of inammatory media-
tors. The magnitude of this insult is proportional to the completeness and duration
of balloon ination, as well as the preocclusion depth and duration of shock [2].
Ischemia results in depletion of cellular energy stores. When perfusion is restored,
a post-reperfusion syndrome ensues, which includes the activation and adhesion of
leukocytes and platelets, generation of inammatory mediators, calcium inux into
cells, disruption of cellular membrane ion pumps, generation of free radicals, and
apoptosis. Clinically, the syndrome is characterized by increased vascular permea-
bility, further exacerbating intravascular volume depletion, and washout of myoglo-
bin, potassium, lactate, and microthrombi into the systemic circulation, exacerbating
hyperkalemia and hypocalcemia, and causing rhabdomyolysis and renal failure,
compartment syndromes, and cardiac arrhythmias. Recognition can be difcult
when the sequelae of post-reperfusion syndrome are superimposed on the manifes-
tations of hemorrhagic shock and hypoperfusion, and requires experience and
mature judgment. Injury, REBOA, operation, and post-reperfusion syndrome will
all contribute to systemic inammation.
In short, the physiological impact of aortic occlusion is profound, and incom-
pletely understood, but has to be managed. The remainder of this chapter deals with
clinical strategies to help surgeons and anesthesiologists when managing the resus-
citation of patients who required REBOA. However, evidence to support these
actions is in short supply, and much of it is based on personal experience and extrap-
olation from other settings.
14.3 Communication
Damage control resuscitation requires excellent communication between surgeons
and anesthesiologists, adding REBOA further increases this need. Anesthesiologists
must be told when temporary and denitive hemorrhage control has been attained,
and when attempts will be made to deate the balloon. Surgeons must be told how
resuscitation is progressing, and whether balloon deation can be attempted.
However, the team managing the patient also has many other members. In our
A. Pierce and J. O. Jansen
207
experience, a very rapid brief on entering the operating room, before transferring
the patient to the table, works well. This is often a period of intense activity and
conicting priorities, and requires a rm “Listen in!” to capture everybody’s atten-
tion. The brief does not have to cover all aspects of the patient’s history, but should
include aspects relevant to the subsequent surgical and anesthetic management, as
deemed by the attending surgeon and anesthesiologist.
14.4 Crew Resource Management
Along with good communication, it is important to ensure that there are sufcient
staff available to take on all necessary roles, and that staff understand which roles they
have been allocated. In addition to the attending surgeon, there should be two experi-
enced assistants. It is often useful to have a second scrub nurse, and more than one
circulating nurse. It is also helpful to have a “REBOA guard,” to protect the arterial
sheath and catheter during transfer, and while the patient is being prepped and draped,
to prevent accidental dislodgement. As far as the anesthetic team is concerned, it is
helpful to have at least three anesthesiologists. This allows the senior clinician present
to maintain a “30,000-foot” perspective, while others are focusing on gaining venous
and arterial access, and managing anesthetic and transfusion management. The latter
is further helped by designating a “blood monitor” with the sole responsibility of
facilitating the infusion of blood and blood products, and keeping track of what has
been administered. If cell salvage is being used, an additional person may be required.
Many of these roles should be allocated and commenced before the patient arrives in
the operating room, that is, while still in the emergency department.
14.5 REBOA Before or After Anesthesia?
One of the most important and earliest decisions to make is whether to institute
REBOA before or after the patient is anesthetized and intubated—unless this has
already occurred prior to arrival in the emergency department. Both approaches
have advantages and disadvantages.
Early anesthesia and intubation ensure that operative treatment can commence
almost immediately. It also reduces patient awareness and discomfort, if the patient
is still conscious. A theoretical disadvantage is that induction may precipitate a fur-
ther decrease in preload, and precipitate a worsening of the patient’s cardiovascular
status, or even a “cardiac arrest” (although the spectrum between severe hypotension
and lack of a palpable pulse is a continuum). However, experience from the wars in
Iraq and Afghanistan has shown that “the patient is too unwell to anesthetize” is
probably no longer a valid concept. In experienced hands, with appropriately chosen
and dosed agents (see below), any patient can be anesthetized and intubated, which
undoubtedly facilitates endovascular (and subsequent surgical) management.
However, there may be occasions when endovascular balloon occlusion prior to
anesthesia and intubation should be considered. Examples include delays in the
14 Management oftheUnstable Patient During EVTM andREBOA
208
arrival of the anesthetic team, whether caused by multiple casualties, or the set-
ting—in particular, when REBOA is used in prehospital care. In these instances,
initial REBOA, facilitated by sedation and local anesthesia, may well be a suitable
strategy. However, it should be borne in mind that these patients are often obtunded
as a result of cerebral hypoperfusion, and that aortic occlusion and restoration of
cerebral perfusion may result in a sudden improvement in the patient’s level of con-
sciousness, requiring proactive management.
14.6 Nonarterial Circulatory Access
Typically, large central venous access is preferred; however, if this is unavailable,
large bore peripheral IVs can sufce. This access is preferably placed in the upper
body venous system, as venous return from the lower body is probably impaired.
Paradoxically, during aortic occlusion, volume resuscitation sometimes has to be
limited, due to the concern for upper body circulatory overload. As a result, there is
an expected need for rapid resuscitation immediately following balloon deation,
with return of the dilated and relatively empty lower circulatory system. This is
facilitated by good venous access. Lastly, if vasoactive drugs are required, central
venous access is also helpful.
14.7 Induction ofAnesthesia
Anesthetic induction must be performed with the patient’s cardiovascular and neu-
rologic status in mind, with the goal of maintaining and optimizing perfusion.
Achieving this goal requires careful consideration of the available medications and
their pharmacological properties, and continuous observation of the patient’s hemo-
dynamic state, along with preparations for rapidly responding to sudden hypoten-
sion. All medications used for anesthetic induction are capable of causing an abrupt
and deleterious decrease in blood pressure and perfusion. Patients who are facing
imminent death exhibit a strong “stress response,” with high catecholamine output.
Induction of anesthesia results in a loss of sympathetic tone, which can result in
profound hypotension. Another consideration is that these patients exhibit a
decreased volume of distribution, secondary to blood loss, and also decreased men-
tal acuity. Both of these conditions necessitate signicant reductions in sedative
medication dosing.
The most common agents chosen for Rapid Sequence Induction (RSI) of anes-
thesia in the severely injured are ketamine and etomidate. Generally, these agents
cause less hypotension and thus less hypoperfusion than other induction agents
(such as propofol and thiopental), but are not without their own concerns, which
require careful consideration [3]. Ketamine has historically been said to be associ-
ated with increases in intracranial and intraocular pressures. Currently, however,
these concerns are deemed to be either unfounded or clinically irrelevant [4]. While
A. Pierce and J. O. Jansen