title: A Modern Case Series of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in an Out-of-Hospital, Combat Casualty Care Setting.
abstract: BACKGROUND
  Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to mitigate bleeding and sustain central aortic pressure in the setting of shock. The ER-REBOA™ catheter is a new REBOA technology, previously reported only in the setting of civilian trauma and injury care. The use of REBOA in an out-of-hospital setting has not been reported, to our knowledge.
  
  
  METHODS
  We present a case series of wartime injured patients cared for by a US Air Force Special Operations Surgical Team at an austere location fewer than 3km (5-10 minutes' transport) from point of injury and 2 hours from the next highest environment of care-a Role 2 equivalent.
  
  
  RESULTS
  In a 2-month period, four patients presented with torso gunshot or fragmentation wounds, hemoperitoneum, and class IV shock. Hand-held ultrasound was used to diagnose hemoperitoneum and facilitate 7Fr femoral sheath access. ER-REBOA balloons were positioned and inflated in the aorta (zone 1 [n = 3] and zone 3 [n = 1]) without radiography. In all cases, REBOA resulted in immediate normalization of blood pressure and allowed induction of anesthesia, initiation of whole-blood transfusion, damage control laparotomy, and attainment of surgical hemostasis (range of inflation time, 18-65 minutes). There were no access- or REBOArelated complications and all patients survived to achieve transport to the next echelon of care in stable condition.
  
  
  CONCLUSIONS
  To our knowledge, this is the first series to demonstrate the feasibility and effectiveness of REBOA in modern combat casualty care and the first to describe use of the ER-REBOA catheter. Use of this device by nonsurgeons and surgeons not specially trained in vascular surgery in the out-of-hospital setting is useful as a stabilizing and damage control adjunct, allowing time for resuscitation, laparotomy, and surgical hemostasis.
authors.forename: Justin D
authors.initials: JD
authors.lastname: Manley
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Mitchell
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: DuBose
authors.forename: Todd E
authors.initials: TE
authors.lastname: Rasmussen
mesh_terms: D001011:Aorta; D021721:Balloon Occlusion / Q000379:methods*; D001803:Blood Transfusion; D004632:Emergency Medical Services / Q000379:methods*; D057510:Endovascular Procedures / Q000379:methods*; D006470:Hemorrhage / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D006801:Humans; D008887:Military Medicine; D008889:Military Personnel; D012151:Resuscitation / Q000379:methods; D025321:Surgery, Computer-Assisted; D014463:Ultrasonography; D000067398:War-Related Injuries / Q000000981:diagnostic imaging / Q000628:therapy*; D014948:Wounds, Gunshot / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy*