The Use of REBOA in a Zone Trauma Center Emergency Department for the Management of Massive Hemorrhages Secondary to Major Trauma, with Subsequent Transfer to a Level 1 Trauma Center for Surgery After Hemodynamic Stabilization

Abstract

Introduction: Non-compressible torso hemorrhage (NCTH) is a major cause of preventable mortality in trauma, particularly when immediate surgical intervention is not available. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has emerged as a promising technique to control severe hemorrhaging and stabilize patients until definitive surgical care can be performed. Case Presentation: We report the case of a 45-year-old woman who sustained multiple traumatic injuries—including thoracic, pelvic, and aortic damage—after a fall from approximately 5 m in an apparent suicide attempt. She arrived at a secondary-level trauma center in profound hemorrhagic shock, unresponsive to standard resuscitation. Interventions: As the patient’s condition deteriorated to cardiac arrest, an emergent REBOA procedure was performed by emergency physicians. This intervention rapidly restored hemodynamic stability, enabling damage control resuscitation and safe transfer to a Level 1 Trauma Center for definitive surgical management, including thoracic endovascular aortic repair and splenectomy. Outcomes: After prolonged intensive care, the patient recovered sufficiently to be discharged for rehabilitation. This case illustrates the life-saving potential of early REBOA deployment in a non-surgical, resource-limited setting to bridge patients to definitive care. Conclusions: This case supports integrating REBOA into emergency trauma protocols, particularly in centers without immediate surgical capabilities. Further research is warranted to refine REBOA deployment strategies, balloon positioning, patient selection, and the role of imaging guidance.

1. Introduction

Non-compressible torso hemorrhage (NCTH) is a leading cause of preventable death in trauma patients, often demanding urgent surgical intervention [1,2]. However, not all trauma centers have immediate surgical capabilities, and traditional resuscitative measures—such as fluid resuscitation, blood product transfusion, and vasopressor support—may fail to stabilize patients rapidly enough to prevent cardiac arrest. This situation creates a critical gap in current trauma management protocols: How can severely bleeding patients be kept hemodynamically stable in settings where the immediate surgical control of hemorrhaging is not readily available?

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has emerged as a promising technique for temporarily controlling hemorrhaging, effectively “buying time” until definitive surgical repair can occur [3,4]. While REBOA has demonstrated potential benefits, its use has primarily been described in high-resource settings—such as Level 1 Trauma Centers—and often involves specialists such as trauma surgeons or vascular surgeons with advanced endovascular training [5,6]. While REBOA shows promise, its application requires careful patient selection, precise balloon positioning, and advanced procedural training due to risks such as ischemia and vascular injury. Prolonged aortic occlusion times, exceeding 40–50 min, may lead to lethal ischemia–reperfusion injuries [7,8]. Current research focuses on refining REBOA protocols, improving balloon placement strategies, and integrating imaging modalities [9].

As a result, several key knowledge gaps remain:

• Limited Data from Lower-Level Trauma Centers: The current literature provides insufficient insight into whether REBOA can be safely and effectively performed in secondary-level trauma centers or “Zone Trauma Centers” that lack immediate access to surgical care. Understanding REBOA’s feasibility and impact in these environments is essential to broadening its practical use.
• Non-Surgeon Operators and Resource Constraints: There is a need for evidence evaluating REBOA deployment by non-surgical emergency physicians or intensivists. If demonstrated feasible, this would expand REBOA’s availability to more trauma victims, particularly where advanced surgical teams are not immediately on hand.
• Bridging the Transfer Gap: The role of REBOA as a bridge between initial stabilization at a lower-level center and subsequent transfer to a higher-level trauma facility for definitive surgery remains insufficiently explored. Establishing protocols for safe inter-facility transfer with REBOA in place could significantly improve patient survival.
• Optimal Timing, Patient Selection, and Imaging Integration: Although initial guidelines emphasize the importance of minimizing balloon occlusion time and carefully selecting candidates, further data are needed to refine these criteria in resource-limited settings. Additionally, the integration of imaging guidance (e.g., ultrasound and CT) to ensure correct balloon placement and reduce complications is not yet standardized outside of advanced centers.

This case report addresses these gaps by illustrating the successful use of REBOA in a Zone Trauma Center without immediate surgical backup. The patient, who arrived in profound hemorrhagic shock and subsequently experienced cardiac arrest, was stabilized through timely REBOA deployment by emergency physicians. This facilitated damage control resuscitation and safe transfer to a Level 1 Trauma Center, where definitive surgical management took place. By detailing this scenario, we contribute to the evolving conversation on REBOA’s applicability beyond its conventional use by surgical teams in tertiary hospitals. Our case provides insights into the decision-making process, training considerations, and procedural adaptations that can make REBOA a viable lifesaving intervention even in resource-constrained settings.

2. Materials and Methods

2.1. Patient Information and Presentation

This case report adheres to the principles of the CARE checklist to ensure comprehensive and transparent reporting. A 45-year-old woman was brought to our emergency department (ED) following a witnessed fall from a height of approximately 5 m in an apparent suicide attempt. Emergency medical service (EMS) personnel reported the patient as unresponsive at the scene and performed intubation for airway protection prior to transport. Upon arrival, the patient exhibited severe hemodynamic instability, with a blood pressure of 52/30 mmHg, a heart rate of 167 beats per minute, and a shock index of 3.2, consistent with profound circulatory collapse. Capillary refill time exceeded 3 s, indicating significant hypoperfusion.

Physical examination revealed symmetrical chest expansion without cranial trauma, a midline trachea, and flat jugular veins. A pelvic fracture was suspected based on left lower limb internal rotation, prompting the application of a T-POD^® pelvic stabilization device. Initial airway management included continued mechanical ventilation with adequate end-tidal CO₂ levels (47 mmHg). Cardiac auscultation revealed tachycardia with normal heart sounds, and the abdominal examination was unremarkable. No additional injuries were noted during a cautious log roll.

2.1.1. Timeline of Clinical Events

The sequence of clinical events is summarized in Figure 1, illustrating the critical decision points and interventions undertaken from prehospital care to transfer for definitive treatment. The timeline highlights the timely deployment of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which played a pivotal role in stabilizing the patient for transfer.

2.1.2. Diagnostic and Initial Management

Initial diagnostic imaging included chest and pelvic radiographs, which revealed the following details:

• Subcutaneous emphysema on the right chest wall.
• A small right apical pneumothorax.
• Fractures of the right 6th to 8th ribs.
• Bilateral comminuted fractures of the iliopubic rami and a left acetabular fracture.

An Extended Focused Assessment with Sonography for Trauma (E-FAST) showed no evidence of massive pneumothorax or pericardial effusion but indicated bilateral basal fluid collections and hyperechoic areas in the spleen suggestive of injury. Laboratory results confirmed severe hyperlactatemic metabolic acidosis (pH 7.21, lactate 6 mmol/L), moderate leukocytosis, and evidence of coagulopathy (INR 1.4, fibrinogen 187 mg/dL).

Damage control resuscitation was initiated with a 1000 mL bolus of Ringer’s lactate, 1 g of intravenous tranexamic acid, and a transfusion of blood products, including packed red blood cells, fresh frozen plasma, and pooled platelets. Hypocalcemia was corrected with calcium chloride, and metabolic acidosis was managed with sodium bicarbonate. Vasopressor support was provided via norepinephrine infusion to maintain perfusion pressure.

2.1.3. REBOA Deployment

Despite aggressive resuscitation, the patient’s condition deteriorated, culminating in cardiac arrest. Advanced cardiac life support (ACLS) protocols were initiated, and the decision was made to deploy a REBOA catheter as an emergency intervention to restore hemodynamic stability. A Reliant™ REBOA catheter (Medtronic, Dublin, Ireland) was inserted percutaneously via the femoral artery and positioned in Zone 1 of the aorta. Placement was confirmed visually using catheter markings. balloon was inflated, resulting in the return of spontaneous circulation, with blood pressure increasing to 155/62 mmHg (Figure 2).

2.1.4. Transfer and Imaging

Following stabilization, a full-body contrast-enhanced CT scan confirmed an aortic rupture extending from the isthmus to the arch. Additional findings included thoracic vertebral fractures (T5 and T9) and a transverse sacral fracture. The REBOA catheter was repositioned under imaging guidance after it was found to be partially in a false lumen. The patient was then prepared for transfer to a Level 1 Trauma Center.

3. Results

Outcome: The patient was successfully weaned off vasopressors and underwent percutaneous tracheostomy 5 days after her hospital admission. Her ICU stay lasted 43 days, after which she was transferred to a general trauma ward. Despite the high-risk nature of her injuries and the complexity of interventions, the patient’s recovery trajectory was positive. Upon discharge, she was stable, with plans for rehabilitation to address mobility limitations due to pelvic fractures.

4. Discussion

This case exemplifies the critical role of REBOA^® in managing life-threatening non-compressible hemorrhages, particularly in settings lacking immediate surgical capabilities. The successful deployment of REBOA^® in a Zone Trauma Center (ZTC) provided a vital “bridge to surgery”, enabling the patient’s transfer to a higher-level trauma facility approximately 20 min away [10]. By employing partial and intermittent occlusion techniques, we adhered to the intended 30 min occlusion time while maintaining distal perfusion. This approach mitigated the risk of ischemia–reperfusion injury, a common complication associated with prolonged aortic occlusion [5,6]. The patient’s minimal post-procedural complications—such as mild renal, gastrointestinal, and lower limb distress—suggest that partial occlusion can reduce the severity of ischemic injuries.

The case underscores the life-saving potential of early REBOA^® deployment when conventional resuscitative efforts are insufficient. Prompt intervention stabilized the patient’s hemodynamics, prevented cardiac arrest progression, and facilitated subsequent surgical management [7,9,11]. Timing is crucial; the delayed use of REBOA^® may diminish its effectiveness and increase the risk of adverse outcomes. Careful patient selection is imperative due to the associated risks, including vascular injuries, limb ischemia, and organ dysfunction from extended occlusion times [5,6]. Adhering to current guidelines that recommend minimizing occlusion duration and continuously monitoring distal perfusion is essential to limit complications [12].

Alternative interventions, such as direct damage control radiology (e.g., arteriographic embolization), can be beneficial in specific cases involving severe pelvic or abdominal hemorrhage. However, the urgency of the patient’s condition and limited access to immediate radiologic intervention made REBOA^® the most viable option in this scenario. Advances in REBOA^® technology, including partial and intermittent occlusion capabilities, aim to further reduce risks by allowing controlled reperfusion during transport or resuscitation [8,13].

The successful implementation of REBOA^® highlights the necessity of a coordinated, multidisciplinary approach. Simulation-based training and continuous education have been shown to enhance provider competence and confidence in REBOA^® deployment [14]. Given the procedure’s complexity and risks, it is crucial to prioritize operational training for emergency department personnel, especially in facilities where immediate surgical intervention is unavailable. Mastery of REBOA^® can significantly improve patient outcomes by effectively bridging patients to definitive care, even in regional trauma centers without direct access to advanced surgical resources.

5. Conclusions

This case demonstrates the effective use of REBOA^® in managing severe hemorrhagic shock resulting from traumatic injuries when traditional resuscitation methods are insufficient. Timely intervention with REBOA^® provided temporary stabilization, enabling safe transfer to a higher-level trauma center for definitive care. The case reinforces the importance of early deployment and appropriate patient selection to optimize outcomes. Further research is essential to refine REBOA^® techniques, enhance patient selection criteria, and integrate advanced imaging modalities to improve trauma care outcomes. Prioritizing training in REBOA^® deployment for emergency department personnel is crucial to enhance readiness and efficacy in handling severe trauma cases, ultimately improving patient survival rates.