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Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)? by Endovascular Resucitation and Trauma Management / Uso actual del bal贸n de resucitaci贸n a贸rtico endovascular (REBOA) en trauma

EMS Solutions International |


The new edition of #JEVTM from the #EVTM society, is out and in print

PDF聽


7mo simposio EVTM en 脰rebro馃嚫馃嚜, 3 al 5 de diciembre 2021

resuscitation hibrida. @StcuaeC @estesonline @talherer @ACSInterntl http://emssolutionsint.blogspot.com/2017/09/resuscitative-endovascular-balloon.html

#EVTM #REBOA



It is a great pleasure to welcome you to the 7th EndoVascular rescucitation and Trauma Management round table symposium to be held in 脰rebro, Sweden, December 3-5, 2021.

Our goal is to offer an excellent scientific program and an outstanding exhibition of the latest treatment options and technology within Endovascular and hybrid rescusitation. With an international faculty of renowned experts and clinicians we will cover most aspects of Endovascular resuscitation, trauma and bleeding management, REBOA, Endovascular technologies and tools as well as new concepts and algorithm for bleeding management from pre-hospital to the post-surgical period.

The EVTM round table symposium is inspired by the collaboration with many centers and its extensive array of experimental research and clinical knowledge in Endovascular and hybrid resuscitation including REBOA. We aim for good cooperation, open discussions and debate as well as high scientific data exchange. The EVTM round table symposium offers a new, modern, live platform and we hope that you will be a part of it.


In the name of the symposium chairs and scientific committee and the local organizers,


Tal H枚rer

脰rebro University Hospital

Sweden


https://www.mkon.nu/evtm2021



Resuscitative Endovascular BalloonOcclusion of the Aorta (REBOA)聽PDF



Army research addresses top cause of battlefield injury, death By Suzanne Ovel, Regional Health Command PacificJuly 2, 2019
https://www.army.mil/article/224078/madigan_research_affects_top_battlefield_injury?fbclid=IwAR2xDtPTWG6_oIk35NIrB24726ZRx60MYBzb71xjxGUjxF1leSaWDfp10dY



聽Endovascular Resuscitation in Trauma Management
A帽adir Endovascular Resuscitation in Trauma Management








Endovascular Resucitation and Trauma Management


REBOA: Resuscitative Endovascular Balloon Occlusion of the Aorta. REBOA is a technique used in trauma for patients that are rapidly bleeding to death from injuries to their chest, abdomen or pelvis. THE GOOD DOCTOR heart Surgery.9 feb. 2018
The Good Doctor 1脳6 | the good doctor Best skills |






Post by Dr. Ramon Reyes, MD

The first and only REBOA manual with much more on EVTM techniques!聽



Zone III REBOA


Zone I REBOA




Some of the issues raised in the manual:

-Vascular Access, Tips and Tricks

-Endovascular rescusitation

-Materials and Techniques 鈥 What to Use and When

-ABO/REBOA pREBOA, iREBOA and more

-Pre-Hospital REBOA and military aspects
-Basic Endo and Hybrid Techniques

-Basic Embolization Techniques

-Multidisciplinary Teamwork

-Organ-by-Organ, the Possibilities

-Complications and Pitfalls

-How to think EVTM: How to Perfo
rm EVTM in the聽Field/Emergency Room

You can download excerpts here:
The Art of Endovascular hybid Trauma and bleeding Management 1聽
Top Stent pages 1-65.pdf
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
Top Stent pages 77-99.pdf


























Resucitaci贸n endovascular con bal贸n de oclusi贸n a贸rtico (REBOA) en fracturas p茅lvicas graves con shock hemorr谩gico


ART脥CULO ORIGINAL: Resucitative endovascular ballon occlusion of the aorta for pelvic blunt trauma and life-threatening hemorrhage: A 20-year experience in a Level I trauma center. Pieper a, Thony F, Brun J, Rodiere M, Boussant B, Arvieux C, Tonetti J, Payen JF, Bouzat P. J Trauma Acute Care Surg 2018; 84(3): 449-453. [Resumen] [Art铆culos relacionados]
INTRODUCCI脫N: El shock hemorr谩gico es una causa de muerte en el traumatizado grave. El uso del REBOA ("Resucitative Endovascular Ballon Occlusion of the Aorta") se ha incrementado como mecanismo no invasivo de estabilizaci贸n del paciente con inestabilidad hemodin谩mica en diversos traumatismos abdominales y p茅lvicos hasta el tratamiento definitivo; sin embargo, su papel es controvertido.
RESUMEN: Estudio retrospectivo de 20 a帽os de utilizaci贸n de REBOA en pacientes con sospecha de fractura p茅lvica y shock hemorr谩gico. La indicaci贸n para su colocaci贸n fue: inestabilidad hemodin谩mica con presi贸n arterial sist贸lica inferior a 60 mm Hg al ingreso o 90 mm Hg tras resucitaci贸n o parada cardiaca durante la resucitaci贸n. Se utiliz贸 la v铆a de acceso femoral y聽el bal贸n fue inflado en la zona 3 (zona de aorta infrarrenal). Si hubo sospecha de lesi贸n abdominal, 茅sta fue prioritaria y posteriormente se procedi贸 a la colocaci贸n del REBOA. Las lesiones a贸rticas fueron contraindicaci贸n para su uso. Se analizan entre otros datos: demograf铆a, Injury Severity Score (ISS), morbilidad y mortalidad a las 24 horas y 28 d铆as de ingreso, d铆as de estancia en UCI, d铆as de estancia hospitalaria y d铆as de ventilaci贸n mec谩nica. La eficacia del REBOA fue valorada en t茅rminos de hemodin谩mica y coagulaci贸n antes y despu茅s de colocaci贸n de bal贸n. La seguridad fue evaluada por las complicaciones vasculares, insuficiencia renal, utilizaci贸n de terapia de reemplazo renal y rhabdomiolisis. Hubo un total de 32 pacientes que recibieron REBOA. La ISS mediana fue de 44 puntos, la mortalidad a los 28 d铆as fue 59% y ocurri贸 en 17 pacientes en las primeras 24 horas de ingreso, la media de estancia en UCI fue 35 d铆as y la hospitalaria 81, la media de ventilaci贸n mec谩nica fue de 22 d铆as. Las complicaciones objetivadas fueron: isquemia de extremidades inferiores en 5 pacientes y disecci贸n a贸rtica iatr贸gena en un paciente. No se precis贸 de amputaci贸n de extremidades, aunque se precis贸 de trombectom铆a y bypass vascular en 1 paciente y aponeurotom铆a en dos pacientes. Otras complicaciones fueron insuficiencia renal con tratamiento de reemplazo renal en 11 pacientes y rhabdomiolisis grave en 15 pacientes.
COMENTARIO: Es un estudio importante de 20 a帽os de experiencia del uso del REBOA en pacientes con fracturas p茅lvicas graves e inestabilidad cl铆nica. El estudio muestra que es un procedimiento eficaz para restaurar la hemodin谩mica en pacientes graves. Aunque existen estudios contradictorios con otras publicaciones, su uso es controvertido para ser incluido en gu铆as cl铆nicas. El estudio muestra que las complicaciones renales y vasculares son relativamente importantes (19% vasculares y 34% precisaron de terapia de reemplazo renal aunque no persisti贸 la insuficiencia renal); sin embargo se precisa experiencia para su colocaci贸n y no est谩 exento de complicaciones importantes, aunque su frecuencia no es alta.
Encarnaci贸n Molina Dom铆nguez
Hospital General Universitario de Ciudad Real.
漏 REMI, http://medicina-intensiva.com. Mayo 2018.
ENLACES:
The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). DuBose JJ, Scalea TM, Brenner M, Skiada D, Inaba K, Cannon J, Moore L, Holcomb J, Turay D, Arbabi CN, Kirkpatrick A, Xiao J, Skarupa D, Poulin N; AAST AORTA Study Group. J Trauma Acute Care Surg 2016; 81: 409-419. [PubMed]
Resuscitative endovascular balloon occlusion of the aorta performed by emergency physicians for traumatic hemorrhagic shock: a case series from Japanese emergency rooms. Sato R, Kuriyama A, Takaesu R, Miyamae N, Iwanaga W, Tokuda H, Umemura T. Crit Care 2018; 22(1): 103. [PubMed] [Texto completo]
B脷SQUEDA EN PUBMED:
Enunciado: REBOA en pacientes traumatizados
Sintaxis: REBOA trauma
[Resultados]
[https://www.facebook.com/medicina.intensiva2.0] [https://www.facebook.com/groups/forodeuci/]




La t茅cnica Reboa se consolida en shock hemorr谩gico traum谩tico
Desde hace cinco a帽os se plantea la opci贸n de emplear las t茅cnicas endovasculares desarrolladas para la rotura de aneurismas de aorta en hemorragias que afectan al tronco.

La hemorragia representa una de las principales causas de mortalidad en la enfermedad traum谩tica grave y en los 煤ltimos a帽os se han producido novedades buscando dar respuesta al dispositivo hemost谩tico ideal (prehospitalario: compacto, transportable, activo en condiciones extremas, seguro y eficaz). Adem谩s, se han desarrollado sistemas que aportan un cierre temporal de la herida y mejoras en otros que aplican hemostasia mec谩nica y tratan de mitigar la hemorragia en extremidades, pelvis y zona de uni贸n tronco-extremidades. Igualmente se ha innovado en agentes y dispositivos que aplicados t贸picamente buscan frenar el sangrado (agentes mucoadhesivos, procoagulantes o que concentran factores de coagulaci贸n).

Sin embargo, seg煤n ha comentado Mar铆a 脕ngeles Ballesteros, del Servicio de Medicina Intensiva del Hospital Universitario Marqu茅s de Valdecilla (Santander), en el LI Congreso de la Sociedad Espa帽ola de Medicina Intensiva, Cr铆tica y Unidades Coronarias (Semicyuc), celebrado en Valencia, estas mejoras no son aplicables a las hemorragias que afectan al聽tronco, dado que no son accesibles ni comprimibles externamente. En ellas, el abordaje habitual implica un clampaje a贸rtico a trav茅s de laparotom铆a o toracotom铆a.

No obstante, ha matizado, desde hace cinco a帽os se ha planteado la opci贸n de emplear las t茅cnicas endovasculares desarrolladas para la rotura de aneurismas de aorta (Resuscitative Endovascular Balloon Occlusion Of The Aorta-Reboa). 鈥淐onsisten en canalizar la arteria femoral com煤n con un introductor y pasar a su trav茅s un cat茅ter que lleva un bal贸n en su extremo distal. 脡ste se ubica en una regi贸n a贸rtica proximal a la zona de hemorragia; una vez inflado se logra una oclusi贸n del flujo a贸rtico y as铆 mitigar el sangrado鈥, ha se帽alado.

Se trata de una herramienta que disminuir铆a la hemorragia, alargar铆a la hora de oro, permitir铆a mejorar el estado hemodin谩mico del paciente o incluso el traslado a centros de referencia de trauma para realizar un tratamiento quir煤rgico definitivo. Recientemente se han publicado resultados de estudios prospectivos, 鈥渕ostrando que es una t茅cnica prometedora que podr铆a integrarse en la cadena asistencial que atiende al paciente con traumatismo grave y que debe ser aportado por centros de trauma donde los profesionales tengan la competencia de proporcionar una asistencia de calidad鈥.

Sin embargo son necesarios estudios que precisen la poblaci贸n diana y mejoras t茅cnicas que permitan superar las limitaciones que se han detectado en la actualidad (sistemas de control din谩mico de la oclusi贸n, control del flujo distal al bal贸n鈥), adem谩s de facilitar la adquisici贸n de esta competencia a los equipos de trauma.

Claves de Radiolog铆a intervencionista
Jos茅 Joaqu铆n Mart铆nez, jefe de Servicio de Radiolog铆a y responsable de Radiolog铆a Vascular e Intervencionista del Hospital Universitario y Polit茅cnico La Fe de Valencia, ha se帽alado que las claves del manejo en trauma grave 鈥渟on la r谩pida respuesta y coordinaci贸n con los Servicios de Urgencias e Intensivos鈥. En este contexto, 鈥渃onocer y saber aplicar las diferentes t茅cnicas que ofrece es fundamental para obtener buenos resultados鈥. Asimismo, ha hecho hincapi茅 en que 鈥渓a disponibilidad de guardias o alertas de Radiolog铆a Intervencionista es esencial para poner a disposici贸n de estos pacientes la cartera de servicios de estas unidades y que permiten abordajes muy eficientes y poco invasivos鈥.

La alta especializaci贸n que se requiere para obtener resultados excelentes y reproducibles 鈥渆xige una pol铆tica adecuada de formaci贸n, de dotaci贸n de estas unidades (personales y materiales) y una optimizaci贸n de los recursos, que pasa por la creaci贸n de redes multidepartamentales que permitan compartir el conocimiento de forma transversal y optimizar y homogeneizar protocolos para permitir finalmente la creaci贸n de guardias unificadas tambi茅n multidepartamentales鈥. El abordaje seg煤n las premisas anteriores 鈥減ermite salvar vidas con enorme eficiencia ahorrando a los pacientes cirug铆as a veces agresivas, permitiendo salvar 贸rganos, acortando estancias hospitalarias y disminuyendo secuelas postraum谩ticas鈥.
Junio 21/2016 (Diario M茅dico) Fuente: Noticias de Salud Al d铆a





http://en.evtm.org/

Combat-tested abdominal/junctional tourniquet proven equivalent to REBOA

https://www.trauma-news.com/2019/08/combat-tested-abdominal-junctional-tourniquet-proven-equivalent-to-reboa/




Combat-tested abdominal/junctional tourniquet proven equivalent to REBOA


BY TRAUMA NEWS ON AUGUST 16, 2019 SOLUTIONS
Recent wartime experience has demonstrated that tourniquets can save lives. Yet many common military and civilian injuries 鈥 particularly armpit and groin injuries and pelvic fractures 鈥 remain difficult to treat in the field. Patients with these injuries are at high risk for bleeding to death.

This article was developed by Trauma System News in cooperation with our advertiser, Compression Works.
Since 2012, special operations forces worldwide have been using an advanced tourniquet device to treat these difficult bleeding injuries 鈥 the Abdominal Aortic and Junctional Tourniquet鈩 (AAJT). Independent research has shown that the AAJT effectively occludes blood flow to the pelvis and the extremities.

鈥淭he AAJT is the only junctional tourniquet that has saved lives endangered by junctional hemorrhage in both the upper and the lower extremities,鈥 said John Croushorn, MD, emergency medicine physician and co-inventor of the device.

鈥淓ven more important, it is the only such device that can also be applied to the abdomen,鈥 he said. 鈥淎s a result, it gives first responders a tool that lets them leverage the 鈥楻EBOA effect鈥 to save patient lives.鈥

Recently, the inventors of the abdominal/junctional tourniquet introduced the AAJT-S (the S stands聽for stabilized). The updated design is not only more secure but faster and easier to apply.

Designed for battle environment
Dr. Croushorn deployed to Iraq in 2004 as a flight surgeon with the Mississippi National Guard. He later worked with U.S. Special Operations units, where he developed a particular interest in bleeding control 鈥 specifically, massive bleeding below the waist.

At the time, one of the newer ideas for controlling lower-body bleeding was to compress the aorta by pressing a knee into the mid-abdomen. After Dr. Croushorn transferred back to the U.S., he supervised a group of resident researchers who validated this technique in a swine model. He and a colleague soon began developing a device to replicate the knee effect.

鈥淲e received FDA approval for our device in early 2012,鈥 Dr. Croushorn said. 鈥淎nd by the end of that year, the original AAJT was in the hands of both American and British special forces.鈥

How to use the AAJT-S
AAJT abdominal placement
Abdominal placement, demonstrated with original device (click to enlarge)

Field application is simple. To apply the AAJT-S to the mid-abdomen:

Buckle the device around the waist by passing the plastic ladder strap under the patient
Insert the ladder strap into the ratcheting buckle until the red mark on the ladder strap meets the red guide on the buckle
Position the main unit over the target area
Pull belt tight, taking all the slack out of the system
Tighten the ratchet until the device is tight around the patient
Inflate the device鈥檚 wedge-shaped bladder until the pressure indicator shows green (250 mmHg)
鈥淎s the wedge inflates, it pushes into the patient, cutting off blood flow through the descending aorta at or near the bifurcation,鈥 Dr. Croushorn said. 鈥淵ou keep inflating the device until it reaches 250 mmHg, which is indicated by a green zone on the pressure gauge. We teach users to go for the green.鈥

The entire process takes about a minute. The updated design鈥檚 strap-and-ratchet mechanism makes application faster than ever. In addition, all controls are now in the front of the device, allowing for greater ease of use under challenging emergency conditions.

When applied to the abdomen, the AAJT-S can safely remain in place for 60 minutes. The AAJT-S also has FDA 510(k) approval for treating junctional hemorrhage at the groin or axilla. When applied to a junction, the device can remain in place for up to 4 hours.

鈥淭he original AAJT was first used by the British in 2013 to treat an Afghan soldier who was injured by an IED,鈥 Dr. Croushorn said. 鈥淗e lost both legs and had serious pelvic injuries and was frankly dying, but they put the device on him and he survived.鈥

鈥淩EBOA effect鈥 in one minute
According to Dr. Croushorn, the AAJT-S mimics the effect of resuscitative endovascular balloon occlusion of the aorta (REBOA).

鈥淩EBOA stops massive bleeding and confines the blood volume to the heart, brain and kidneys, so it can be a life-saving intervention for severely bleeding patients,鈥 he said. 鈥淯nfortunately, REBOA is limited right now to hospital use by a physician 鈥 and most patients who might benefit from it will bleed out before they even reach the hospital.鈥

AAJT axilla placement
Axilla placement, demonstrated with original device (click to enlarge)

In August 2017 independent investigators from the U.S. Army Institute of Surgical Research and the Air Force鈥檚 59th Medical Wing presented research showing that the abdominal/junctional tourniquet is equivalent to Zone 3 REBOA. (Journal of Surgical Research, Volume 226, June 2018)

鈥淚n addition, the Air Force group looked specifically at traumatic cardiac arrest,鈥 Dr. Croushorn said. 鈥淭hey found that abdominal/junctional tourniquet application and blood transfusion led to 83% survival compared to 17% survival with blood and CPR alone.鈥 (Military Medicine, Volume 182, September 2017)

鈥淔or years we taught medics that if a patient is in cardiac arrest from bleeding out, there is no reason to do CPR,鈥 he said. 鈥淣ow, with the AAJT-S, we can actually save most of these people, and that鈥檚 because of the REBOA effect of this device.鈥

Paramedics can use the AAJT-S to achieve the physiologic benefits of REBOA at the point of injury. The device can also be deployed in the ED as a 鈥渂ridge therapy鈥 while waiting for a trauma surgeon or emergency medicine physician to apply REBOA.

鈥淭he AAJT-S opens up the opportunity to achieve the benefits of REBOA much earlier,鈥 Dr. Croushorn said. 鈥淲e can鈥檛 put a trauma surgeon in every ambulance, but we can give medics the capability to do what trauma surgeons do.鈥

Effective intervention for pelvic fractures
While the AAJT-S was developed for a military setting, it could also help solve a major problem in civilian trauma 鈥 pelvic fracture bleeding.

The AAJT-S abdominal/junctional tourniquet
The redesigned AAJT-S abdominal/junctional tourniquet (click photo to enlarge)

鈥淚n the U.S., we have 115,000 pelvic fractures per year,鈥 Dr. Croushorn said. 鈥淧aramedics are trained to recognize when the pelvis is broken, but they have no way to know whether a patient is bleeding from that fracture until their blood pressure starts to drop.鈥

In these situations, paramedics are little more than transport providers. 鈥淭hey can鈥檛 help these patients outside of applying a pelvic binder or simply tying a sheet around their hips,鈥 he said. 鈥淭hat can reduce the bleeding volume but it does not stop the bleeding.鈥

For these patients, the AAJT-S is a potentially life-saving tool. Once a paramedic recognizes pelvic fracture, he or she can deploy the device at the mid-abdomen and quickly stop the blood flow to the pelvis.

鈥淭he AAJT-S lets you 鈥榯urn off the faucet鈥 of pelvic bleeding,鈥 Dr. Croushorn said. 鈥淚t provides something that medics can do before they get to the hospital to prevent these patients from going into shock.鈥

Safety and ease of use
AAJT groin placement
Groin placement, demonstrated with original device (click to enlarge)

鈥淥ther junctional devices use point pressure, so they require very precise placement,鈥 Dr. Croushorn said. 鈥淎nd, in fact, if the patient moves it is very easy to lose hemorrhage control.鈥

In contrast, the AAJT-S compresses a relatively large surface area. 鈥淏ecause of that, the user does not have to have specific knowledge of anatomy, so any first responder can place it,鈥 he said. 鈥淭hat also means the device stays in place, even during hasty extractions.鈥

The recent design update includes a wider 3-inch belt that improves stability. In addition, the device is now built around a single platform of tough HDPE plastic, which distributes compression force more effectively.

Compared to other junctional devices, the wider compression area of the AAJT-S also lowers the risk of complications. 鈥淥ther junctional hemorrhage tourniquets reach tissue pressures in the range of 700 to 800 mmHg, which increases the risk of tissue necrosis and nerve death,鈥 Dr. Croushorn said.

The AAJT-S includes an automatic release valve that prevents the pressure from exceeding 300 mmHg. 鈥淚t鈥檚 not much more pressure than you would experience with a blood pressure cuff in your doctor鈥檚 office,鈥 Dr. Croushorn said.

(Read more: Complications of the Abdominal Aortic and Junctional Tourniquet: What the research says.)

A complement to Stop the Bleed
The Stop the Bleed campaign is spreading the use of conventional extremity tourniquets. However, these devices are ineffective in several challenging hemorrhage scenarios.

鈥淭hat鈥檚 why I think the Abdominal Aortic and Junctional Tourniquet has an important role to play in this initiative,鈥 Dr. Croushorn said. 鈥淭he AAJT-S can provide early hemorrhage control for a high-risk subset of bleeding patients 鈥 individuals with dangerous bleeding at junctional sites and the pelvis.鈥

For more information on the AAJT-S, visit CompressionWorks.com. To order the AAJT-S for delivery in the United States, visit the Compression Works store page or North American Rescue. To order for delivery in Europe, visit exclusive EU distributor Fenton Pharmaceuticals. The AAJT-S will also be available from GSA Advantage this fall.

See it at the Military Health Symposium. The AAJT-S will be highlighted at the 2019 Military Health System Research Symposium taking place August 19-22 in Kissimmee, Florida. To see and use the device, visit North American Rescue at Booth聽#601.聽





Dr Ramon REYES, MD,
Por favor compartir nuestras REDES SOCIALES @DrRamonReyesMD, as铆 podremos llegar a mas personas y estos se beneficiar谩n de la disponibilidad de estos documentos, pdf, e-book, gratuitos y legales..

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