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Resuscitative Endovascular Balloon Occlusion of the Aorta: A Gap Analysis of Severely Injured UK Combat Casualties

Morrison, Jonathan J.*†; Ross, James D.; Rasmussen, Todd E.§∥; Midwinter, Mark J.†¶; Jansen, Jan O.**††‡‡

doi: 10.1097/SHK.0000000000000136
Clinical Aspects
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ABSTRACT The control of torso and junctional zone bleeding in combat casualties is particularly challenging because of its noncompressible nature. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has demonstrated promise in translational large animal and early clinical series as an effective resuscitation and hemorrhage control adjunct. However, it is unknown what proportion of combat casualties has an injury pattern and clinical course that is amenable to REBOA deployment. The prospective UK Joint Theatre Trauma Registry was used to retrospectively identify all UK military personnel who has sustained a severe combat injury, defined as an Abbreviated Injury Scale of three or greater, in the course of 10 years. Patients were then divided into three groups based on Abbreviated Injury Scale injury pattern: no indications for REBOA, contraindications (mediastinal, cervical, and axillary hemorrhage), and indications (torso and pelvic hemorrhage). From a total of 1,317 patients, 925 (70.2%) had no indication, 148 (11.2%) had a contraindication, and 244 (18.5%) had an indication for REBOA. Within the group with indications for REBOA, there were 174 deaths: 79 at the point of wounding, 66 en route to hospital, and 29 in-hospital deaths. The median (interquartile range) time to death in patients dying en route was 75 (42–109) min, and the median prehospital time for casualties admitted to hospital was 61 (34–89) min. One-in-five severely injured UK combat casualties have a focus of hemorrhage in the abdomen or pelvic junctional region potentially amenable to REBOA deployment. The UK military should explore REBOA as a potential en route hemorrhage control and resuscitation adjunct.

*Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow; and The Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK; 59th Medical Wing, Lackland Air Force Base (San Antonio), Texas; §The Norman M. Rich Department of Surgery, The Uniformed Services University of the Health Sciences, Bethesda; and US Combat Casualty Care Research Program, Fort Detrick, Maryland; and National Institute of Health Research, Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham; **144 Parachute Medical Squadron, 16 (Air Assault) Medical Regiment; and ††Aberdeen Royal Infirmary and ‡‡NHS Research Scotland, HSRU, Aberdeen, UK

Received 1 Dec 2013; first review completed 20 Dec 2013; accepted in final form 7 Jan 2014

Address reprint requests to Jonathan J. Morrison, MRCS, The Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham, B15 2SQ, UK E-mail:

© 2014 by the Shock Society