SCENE ASSESSMENT AND MANAGEMENT PRIORITIES

Airway

1 It is paramount once on scene for the EMT to determine the status of the patient’s airway. Evaluating the patient’s Glasgow Coma Scale (GCS), chest rise, extent and nature of injuries provides vital insight into whether or not the patient is and will be able to maintain their airway (Tables 20-1 and 20-2). Supplemental maneuvers such as suctioning, chin lift/jaw thrust, placement of oropharyngeal airways, and use of bag-mask devices can temporarily restore oxygenation in the acutely injured patient. These maneuvers will usually maintain airway patency for the patient during their transport to definitive care; for those who are unable to do so, advanced airway maneuvers are key to securing a patent airway. Tracheal intubation provides a definitive airway with a cuffed endotracheal tube that will facilitate oxygenation, ventilation, and prevent aspiration. The skills required to successfully intubate are difficult to achieve and require remediation and oversight to maintain.⁸ There is conflicting literature to support field intubation. Winchell and Hoyt completed a retrospective review of blunt trauma patients with severe head injury in San Diego that found statistically significant decrease in mortality between patients intubated in the field and those who were not.⁶ The only randomized controlled trial of prehospital intubation versus bag-mask ventilation occurred in 2000 with pediatric patients, and it showed that the addition of out-of-hospital intubation did not improve survival or neurologic outcomes.⁹ A retrospective review of prehospital intubation versus bag-mask ventilation by Stockinger and McSwain showed no survival advantage to intubation and an increased prehospital time.⁸ The majority of literature suggests that prehospital intubation does not improve survival and may prolong time to definitive care.¹⁰ One meta-analysis evaluating emergency intubation for the acutely ill showed no survival benefit in nontraumatic cardiac arrest prehospital intubation, as well as no evidence of prehospital intubation benefitting trauma patients in the urban environment.¹¹ While the majority of situations in the prehospital setting do not require intubation, there are some that make sense to secure an airway. Patients who have evidence of extensive facial trauma, patients who will require long transport times to reach definitive care, and those patients who are apneic due to suspected cervical injury are appropriate to intubate in the prehospital setting. The reflexive intubation to “protect” the airway should be avoided, and further randomized studies are required to truly answer the question of who and when to intubate in the prehospital setting.

There are alternative measures that can be taken for those who need to establish an airway but do not have the skills for intubation. Laryngeal mask, Combitube, and King Airway all require less training and skill for insertion, however, they have never been shown to increase survival. While the invention of video-assisted airway insertion devices has taken hold in the hospital setting for “difficult” airways, its use in the prehospital setting has not been studied in depth. A retrospective review of patients in Europe showed the prehospital use of the Glidescope facilitated successful intubation when conventional direct laryngoscopy failed.¹² This study is limited by its small size and retrospective nature, however, as technology advances the use of video-assisted airway devices may allow for more successful prehospital intubation. Whether or not these devices will increase survival in patients is unknown at this time. A surgical cricothyroidotomy (CRIC) can provide an emergency airway in the hands of skilled practitioners. This maneuver requires much training and is usually utilized by military personnel in austere environments, or after failed orotracheal intubation efforts. A retrospective review by the Israeli Defense Force showed a 93% success rate with CRIC for patients requiring an emergency airway.¹³

Breathing

Assessment of patient’s breathing occurs simultaneously with airway assessment. Evaluation of symmetric chest rise, obvious signs of chest trauma, and presence of bilateral breath sounds give the first responder an idea of the patient’s status. The presence of a tension pneumothorax is a life-threatening event that may lead to obstructive shock, hemodynamic collapse, and potentially death. EMTs may also identify a patient with a tension pneumothorax with the presence of tracheal deviation, neck vein distention, and cyanosis. Prompt decompression of the thoracic cavity with a needle is necessary to reverse the tension effect. While the traditional landmark has been the midclavicular line, cadaver and computerized tomography evaluations had demonstrated more consistent evacuation of air using the anterior axillary, especially in females.¹⁴ Further management with tube thoracostomy will be evaluated once the patient arrives at their receiving facility. Large sucking chest wounds, that permit the rapid equilibration of pleural and atmospheric pressure, can be rapidly fatal. These wounds prevent the lung from expanding and preclude alveolar ventilation. These large wounds cause hemodynamic collapse rapidly unless an airway is obtained that allows for positive pressure ventilation. The very rare smaller open chest wounds are amenable to a three-sided dressing that allows for gas to exit from the chest wall defect but prevents gas from entering the chest wall. These can be fashioned in a field expedient manner and function as a temporizing action until definitive therapy with a chest tube, in a sterile environment, can be achieved.

In addition to gross disturbances and threats to oxygenation and ventilation, prehospital personnel should be aware of these specific interventions as occasionally they can lead to greater harm than the injury itself. Over the last decade, the trauma literature has shown that the manner in which we previously cared for the airway in traumatic brain injury (TBI) may have done more harm than good.^15,16 Hyperventilation in the prehospital setting had been previously advocated, and is unfortunately still occasionally practiced, leading to acute vasospasm in the cerebral blood flow causing an overall decrease in the cerebral blood flow in patients with a severe TBI. This has since been abandoned in favor of normocapnea, decreasing the actual increase in overall cerebral blood flow (and worse outcomes) with hyperventilation.^15,17 Warner et al. in the Journal of Trauma showed that end-tidal CO₂ monitoring in the prehospital setting poorly correlated with the actual arterial blood gas analysis pCO₂, and as such suggested that using it to guide prehospital ventilation status may lead to inadvertent hypercapnia.

Given that many prehospital personnel ventilate patients via bag-valve devices connected to either a facemask or directly to an endotracheal tube, experts in the field and numerous investigators have advocated for the use of end-tidal CO₂ monitoring in these settings.^18,19 Silvestri et al. showed that there were no misplaced endotracheal tubes in patients who had continuous end-tidal CO₂ monitoring (0/93) whereas 23.5% of misplaced (14/60) prehospital intubation did not use monitoring in the prehospital setting. With bag volumes in excess of 1,200 mL, uncontrolled bag ventilation can easily lead to inadvertent hyperventilation. In fact, researchers have shown that almost 80% of end-tidal CO₂ values for intubated TBI patients are <30 mm Hg in the field.²⁰ Patients with severe TBI were shown to have decreased mortality when their PaCO₂ was maintained between 30 and 35, 21.2% versus 33.7% by Warner et al. This paper suggests that prehospital monitoring, along with close continued monitoring of arterial blood gases after admission to the hospital will lead to interval decrease in mortality.

Circulation

Evaluation and treatment of circulatory status in the prehospital setting has undergone much change in the past 10 years. The experiences from the Global War on Terror have rapidly changed the way in which we think about prehospital circulation and how we treat the abnormalities in circulation. Evaluation of circulatory status begins with initial evaluation of mental status and inspection for obvious signs of active hemorrhage. Direct pressure and hemostatic dressings can be used for control of hemorrhage; however, large volume extremity hemorrhage may need to be addressed with placement of a tourniquet. A prospective evaluation of tourniquets applied during Operation Iraqi Freedom showed increased survival with tourniquet placement and no subsequent limb loss due to their use.²¹ Passos et al. reviewed the use of emergency tourniquet use in the civilian setting and found that they prevented exsanguination in the setting of both blunt and penetrating extremity trauma.²⁰

Once the circulatory status of the patient has been addressed, sites of rapid compressible exsanguination identified and treated, the decision is made for intravenous access and possible use of intravenous fluid. In 2009 the Eastern Association for the Surgery of Trauma published their practice management guidelines regarding prehospital fluid resuscitation of the injured patient. These guidelines support placement of peripheral IV or intraosseus access only if it does not delay the transport of the patient, as well as small fluid boluses of 250 cc of hypertonic (3% or 7.5%) saline being equivalent to volume resuscitation with 0.9% normal saline or lactated ringers.²² These guidelines also support minimizing fluid resuscitation until hemorrhage is addressed and not resuscitating those patients with penetrating torso trauma. There is, however, data from the Resuscitation Outcomes Consortium (ROC) that resuscitation with hypertonic fluids versus normal saline did not result in improved 28-day survival.²³ The patients were randomized 250 mL boluses of either hypertonic saline (7.5%) versus hypertonic saline per 6% dextran versus 0.9% normal saline. The study was stopped early due to potential safety concern based on increased mortality in the group that received hypertonic saline. As such, current clinical guidelines do not recommend the regular use of hypertonic saline resuscitation in the severely injured patient.

Further evaluation has led researches to push for earlier transfusion of blood product components as in the prehospital setting. Studies from severe combat casualties showed that an aggressive approach to prehospital blood transfusion was associated with large improvement in mortality; however, further randomized studies were necessary.²⁴ Severely injured patients are now receiving blood transfusion in the civilian setting while en route to facilitate early hemostatic resuscitation and prevention of coagulopathy complications. Brown and colleagues conducted a retrospective, case-controlled analysis of patients who received prehospital packed red blood cells (240 patients) against those who did not (480 patients).²⁵ Their study showed an increased likelihood of 24-hour survival, lower odds of shock, and lower overall 24-hour blood transfused. A subsequent paper from these investigators evaluated over 2,000 blunt trauma patients arrived at one of eight subject institutions within 2 hours of injury.²⁶ Of the 2007 patients, 50 (3.5%) received blood in the prehospital setting, and they were compared to controls who did not. Those patients who received prehospital blood had a 95% reduction in the odds of 24-hour mortality, 64% reduction in 30-day mortality, and an 88% reduction in the incidence of trauma-induced coagulopathy.

In patients without evidence of hemorrhage or in prehospital settings where blood and blood products are not available, numerous choices of fluid are available. However, most fluid options are actually poor choices for resuscitation of injured patients. Normal saline (0.9% sodium chloride) has an average pH of 5.5, with a sodium and chloride concentration of 154 mEq/L. Normal saline is often preferred as a universal solution for prehospital settings as it is “compatible with blood,” contains no potassium, and is cheap to carry; with a low overall cost and extended shelf life. Lactated Ringer’s, initially developed to support organs in the lab (because of calcium content) and later championed for treating cholera, has only a slightly better physiologic profile. Lactated Ringer’s gives the clinician a better average pH of 6.5, with lower sodium (130 mEq/L) and chloride content (109). The optimal fluid, however, is Plasmalyte®/Normosol® which has an average pH of 7.4 and an electrolyte content that resembles a normal metabolic profile (sodium – 140 mEq/L, potassium – 5.0 mEq/L, chloride – 98 mEq/L, and magnesium – 3.0 mEq/L). In addition to its superior profile, Plasmalyte® is compatible with all blood products and has been shown in a randomized trial to result in improved acid–base status and less hyperchloremia at 24 hours postinjury.²⁷ There is increased interest in the use of plasma as a prehospital fluid, be it conventional or freeze dried, and this is reflected in the ongoing Prehospital Use of Plasma in Traumatic Hemorrhage (PUPTH trial).²⁸ The aim of this study is to compare prehospital resuscitation with plasma versus normal saline in patients who are found to be in shock from either blunt or penetrating mechanisms. While results are pending, hopefully this study will shed more light on the ideal type and amount of prehospital fluid for resuscitation.

TRIAGE

Triage is an active process that takes into account multiple factors with the goal of transporting the patient to the correct trauma center in the shortest amount of time. The Centers for Disease Control and Prevention have published guidelines helping to facilitate proper triage of injured patients since 1999. These guidelines underwent their most recent update in 2011 and use physiologic, anatomic, and the mechanisms of the injury to guide the triage of the patient.²⁹ Changes specific to the 2011 update include lowering GCS for the physiologic criteria, broadening the definition of injuries in the anatomic criteria, and addressing the differences in older adult trauma patients relative to young trauma patients. The implementation of these guidelines is key to preventing both under- and overtriage of the acutely injured patient. Undertriage is the practice of sending an acutely injured patient to a lower than needed tier in the trauma system. This leads to prolongation to definitive care for injuries, multiple transfers to identify the correct level of care, and overall worse care of the patient. Overtriage is transferring a patient to a highest-level trauma system when their injuries do not warrant that level of care. This allocates scarce resources to patients who ultimately do not need them, and as such may prevent those who need that resource appropriately from getting it. In 2011, a review of the triage guidelines from 1999 compared to 2006 showed a statistically significant decrease in the number of patients who were overtriaged when the guidelines were followed appropriately.

A special triage situation occurs when multiple patients are injured. A multicasualty event occurs when a hospital is able to manage the number of casualties with local resources. The majority of level 1 trauma centers are able to take care of a small multicasualty event without significant strain on their work environment. A mass-casualty event exists when the numbers, severity, and diversity of injuries overwhelm the local medical resources. A recent example of a mass-casualty event is the April 15, 2013 bombing of the Boston Marathon. A terrorist attack by two terrorists, bent on causing fear and destruction, deployed two homemade improvised explosive devices (IEDs) near the finish line of the race. Two hundred sixty-four patients sought treatment for injuries from the event; there were three fatalities on scene and numerous patients transferred to the five level 1 trauma centers located in Boston.³⁰ An active onsite triage team was able to identify those patients who needed immediate transfer based on criteria and send them to one of the awaiting hospitals for immediate treatment. Specifically, the Brigham and Women’s Hospital received a total of 31 patients immediately following the bombing, of which 23 arrived within the first hour.³¹ Of those transported to the Brigham that day, fifteen patients were admitted to the hospital, nine went to the operating room, and none died. Mass-casualty events require coordination at the state and national level, and extensive practice at implementing triage criteria. Interestingly, in 2002 the city of Boston completed a citywide mass-casualty practice event in response to the 9/11 Attack. Some credit for the successful actions that due has been given to the experience gained from this practice and other drills.

ADVANCES AND CONTROVERSIES

Rapid Sequence Intubation Versus Non-RSI

The use of rapid sequence intubation (RSI) in the prehospital setting is one that engenders much discussion in the prehospital setting. A standard of care in the inpatient setting, the use of RSI in the prehospital setting is both supported and refuted by the literature over time. The drugs that are used for RSI, while no one standard is accepted by everyone, include combinations of the following: diazepam, succinylcholine, vecuronium, midazolam, rocuronium, lidocaine, ketamine, and etomidate. Many argue that the complications that are associated with RSI, including the consequences of multiple failed intubation attempts, unnecessary exposure of patients to dangerous procedure, and complications of the medications do not value the implementation of RSI in the prehospital setting.

A 2005 paper published on the use of RSI in the out-of-hospital setting was unable to predict which patients had severe TBI and over half the patients experienced a desaturation during the RSI procedure, while only one-quarter of they were hypoxic before RSI.³² A further study from the United Kingdom showed an incidence of 18.3% for hypoxemia during prehospital RSI and 13% developed hypotension lower than pre-RSI blood pressures.¹⁶ This paper attributes its lower incidence of hypoxemia and hypotension to the fact that in the United Kingdom board certified Physicians preform all the prehospital RSI and intubations, while in the San Diego paper the entire procedure was carried out by EMTs. Using a propensity-adjusted model, investigators showed no statistical difference in mortality between prehospital intubations with and without RSI. Further randomized, prospective trials are necessary to prove a benefit to prehospital RSI.

Aggressive Fluids Versus Permissive Hypotension

The concept of permissive hypotension involves keeping the blood pressure low enough to avoid exsanguination while maintaining perfusion of end organs.³³ It is an integral part of the new Damage Control Resuscitation protocols that are being implemented; however, its root goes as far back as World War I. The work of Walter Cannon and John Fraser while serving with the Harvard Medical Unit in France involved the observation that artificial elevations in blood pressure may overcome the clot preventing further hemorrhage, and the patient will lose sorely needed blood.³⁴ Fast forward to 1994 when the plenary paper by Bickell et al. showed in a randomized prospective control trial delayed fluid resuscitation in adults with penetrating torso injuries lead to greater survival and overall shorter hospital length of stay.³⁵ These results have been repeated in further subsequent studies by other authors showing no benefit to early aggressive resuscitation, especially to supernormal levels. Finally, Holcomb et al. in 2007 published the plenary paper on damage control resuscitation outlining the two important principles of resuscitating to a systolic blood pressure no greater than 90 and using thawed plasma in a 1:1 or 1:2 ratio with PRBC to restore intravascular volume.³⁶

The concept of permissive hypotension is directly contradictory to the guidelines found in the ATLS manual that advocate for 2 L of crystalloid resuscitation early in those patients manifesting signs of shock. However, a recent multicenter, randomized study by the ROC suggests that a restrictive strategy is warranted in blunt trauma patients as well.³⁷ The investigators randomized hypotensive trauma patients to receive small boluses of fluid (250 mL) if they had no radial pulse or a systolic blood pressure lower than 70 mm Hg or to receive the standard 2-L fluid bolus and additional fluid needed to maintain a systolic of 110 mm Hg or greater. Patients in the hypotensive resuscitation group (fluid for systolic <70 mm Hg) had a lower 24-hour mortality compared to standard resuscitation group (3% vs. 18%).

Schreiber et al. conducted a randomized prehospital trial placing patients into either of two groups: (1) standard resuscitation patients who received 2 L of crystalloid initially and fluid as needed to maintain a systolic blood pressure of 110 mm Hg or greater, or (2) controlled resuscitation patients who received 250 mL of fluid if they had no radial pulse or an SBP lower than 70 mm Hg, with additional 250-mL boluses to maintain a radial pulse or SBP of 70 mm Hg or greater. The controlled resuscitation group received 1 L less of fluid, had less deaths (5% vs. 15%) at 24 hours after admission, and among patients with blunt abdominal trauma 24-hour mortality was 3% versus 18%, all statistically significant. This paper showed that controlled resuscitation in the out-of-hospital setting may offer an early survival advantage to the blunt trauma patient. There was, however, no difference in mortality among patients with penetrating trauma.

2 Further studies are necessary to cement at which level the resuscitation should be stopped; however, we now know that minimal intravenous fluids, tolerating systolic blood pressures in the 75 to 90 mm Hg range, and not resuscitating to supernormal values with crystalloid is the paradigm prehospital trauma workers should follow.

Prehospital Blood Protocols

The lessons from the Global War on Terrorism have changed many paradigms regarding the prehospital care of the acutely injured patient. Some argue that the advent of prehospital blood product transfusion protocols will make the greatest impact on civilian trauma management. Early studies identified the prehospital setting as an ideal place to begin early resuscitation with blood products, as hemorrhage was identified to cause 33% to 56% of the prehospital casualties. In a multicenter study of over 1,400 injured patients with evidence of shock, Brown and colleagues demonstrated an increase in both 24-hour and 30-day survival, as well as less coagulopathy on arrival in those patients receiving prehospital red blood cell (RBC) transfusions.³⁸ Building on this, the Houston group published their aeromedical experience with prehospital plasma and RBC, which began in 2011.³⁹ Similar to the data published from the wars in Iraq and Afghanistan, the investigators noted in their study of almost 1,700 patients that placing RBCs and plasma products in the prehospital setting, allowing for earlier infusion of life-saving products to critically injured patients, was associated with improved early outcomes.

3 The more recent PROPPR trial included patients who received blood transfusion en route and showed that more patients resuscitation in the 1:1:1 group versus 1:1:2 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours.⁴⁰ This study will hopefully spur further prospective, randomized control trials trying to identify the proper type and amount of blood product resuscitation in the prehospital setting.

ETCO₂ Monitoring

4 The use of end-tidal CO₂ (ETCO₂) as a means for measurement of exhaled CO₂ is the standard found in the operating room and emergency room; however, its use in the prehospital setting was not commonplace 10 years ago. ETCO₂ is a reflection of metabolism, circulation, and ventilation. As technology has advanced, the ease of use and application of ETCO₂ monitoring has become more commonplace. ETCO₂ was first used as a way to confirm placement of endotracheal tubes in the prehospital setting using colorimetric CO₂ detector.⁸ The use of the colorimetric detector in conjunction with auscultation and symmetric chest rise make the likelihood of esophageal intubation near zero. This must be prevented as esophageal intubation rates have been reported as high as 17% to 25% in emergency airway management of nonarrest patients.⁴¹ In-line capnography in the nonintubated patient is key to assessing the adequacy of chest compressions in patients undergoing CPR. ETCO₂ has been shown to correlate linearly with coronary artery perfusion pressure, and hence is a simple and noninvasive method to measure blood flow during CPR and can indicate return of spontaneous circulation. In 2009 a study of out of Harborview Hospital showed that documented ETCO₂ in prehospital intubations did not correlate to ABG PaCO₂, with patients most likely being under ventilated (PaCO₂ >40) 80% of the time and severely underventilated (PaCO₂ >50) 30% of the time.⁴² As such, the use of ETCO₂ is to assess for proper endotracheal intubation as well as ascertain effectiveness of CPR is established, however, its ability to predict PaCO₂ will need further study.

Tourniquet Use in the Field

5 Tourniquet use for injury has documentation as far back as 6 BC in Hindu text for the treatment of a snakebite.⁴³ Over time it has fallen in and out of favor in the prehospital setting, however, experiences during the recent Global War on Terror support its use as far forward as possible in the prehospital setting. In the Vietnam War surgeons recognized that of the casualties killed in the war, 2,590 lives could have been saved with better prehospital care namely tourniquets.²¹ Analysis of the casualties of Operation Gothic Serpent, the 1993 battle fought between U.S. forces and the militias in Somalia, showed 7% of fatalities resulted from penetrating extremity trauma and that hemorrhage control in the form of tourniquet use should be more widely adopted.⁴³ The current conflict in Iraq and Afghanistan brought out the strongest data supporting the use of prehospital tourniquets. A prospective study of casualties over a 7-month period in 2006 at a combat hospital in Baghdad showed tourniquet application with the abscence of shock was strongly associated with survival, no amputations resulted solely from tourniquet use, and only four nerve palsies at the level of the tourniquet occurred all of which resolved without issue.²¹ Further papers have gone on to show civilian application of this concept also saves lives and limbs. In 2015, Scholl et al. published a retrospective review of civilian trauma patients admitted with a prehospital tourniquet at nine institutions. Their data show overall mortality and limb amputation rate in statistically similarly injured patients was less than that seen in military data previously documented. A final, more fatal, type of hemorrhage is junctional hemorrhage defined as bleeding from the pelvis, groin, perineum, axilla, and neck. These wounds were seen extensively in the Global War on Terrorism as the use of IED increased. Holcomb et al. reviewed preventable causes of death in U.S. Special Forces Soldiers in 2007 and found that junctional or noncompressible trauma was implicated in 47% of deaths.⁴⁴ A future place for research, the junctional tourniquet has shown in healthy volunteers to occlude blood flow to the lower extremity.⁴⁵ While these experiences are mainly from combat environments, application to the civilian field has been successfully implemented.⁴⁶ A paper out of the trauma group at USC showed that prehospital use of tourniquet, be it Combat Application Tourniquet, field expedient tourniquet, or pneumatic tourniquet placed in the emergency room, is associated with no increased rate of complications.⁴⁷ Of note from this study, only 50.6% of the tourniquets were placed in the prehospital setting, leading to further question as to whether or not full implementation of prehospital tourniquets would lead to further success in preventing mortality and decreasing complications from traumatic extremity injuries. A subsequent multi-institutional retrospective analysis of prehospital tourniquet use showed lower overall mortality and limb amputation rates when compared to historical combat data.⁴⁸ This paper showed that extrapolation of military data, as well as practices, to the civilian trauma patient leads to increased survival and limb salvation.

Resuscitative Endovascular Balloon Occlusion of Aorta

Resuscitative endovascular balloon occlusion of aorta (REBOA) is a balloon placed via the femoral artery to occlude the aorta and prevent life-threatening hemorrhage (Fig. 20-1). While the technology is new, the idea is not as it is described in an article in the journal Surgery in 1954 for controlling intra-abdominal hemorrhage. Multiple animal studies have shown that REBOA is superior to emergency thoracotomy with aortic clamping to control hemorrhagic shock in the porcine model.⁴⁹ Control of hemorrhage far forward in the military combat environment is the goal of the REBOA. A retrospective analysis of UK combat casualties, 18.5% had an indication for REBOA when reviewing their injuries.⁵⁰ While it is rapidly gaining popularity as a substitute for resuscitative thoracotomy, it is probably best suited for quickly controlling pelvic hemorrhage (before the patient has lost pulses) prior to embolization and interventional radiology availability. Research is now being produced that shows a benefit to REBOA use for hemorrhage control. Brenner et al. published a series of six cases in 2013 that outlined the successful implementation for hemorrhage control of REBOA.⁵¹ Successful implementation of REBOA in these six cases showed that endovascular aortic occlusion supports myocardial and cerebral perfusion until resuscitation can be initiated and hemostasis obtained, the same goals of aortic cross clamping in a markedly less invasive manner. Further research published in 2015 compared the outcomes of REBOA versus resuscitative thoracotomy for noncompressible truncal hemorrhage. In clinically similar groups, the REBOA group had fewer early deaths, improved overall survival (37.5% vs. 9.7%, p = 0.003) with less morbidity than the resuscitative thoracotomy group.⁵² While this took place in only two centers with advanced skills with REBOA, it is feasible that continued training in endovascular skills during both the training and attending years may lead to greater implementation of this skill. The Japanese have published a retrospective review of their experience with the safety and feasibility of REBOA for trauma in 2014.⁵³ Their data show that REBOA was feasible for trauma resuscitation, however, there was an increased risk of lower limb ischemia and possible amputation that occurred in 12.5% of their patients. New technologic advances producing small sheaths and smaller balloons may eliminate the need to close an arteriotomy required of larger sheaths and thus decrease this risk. Further forward management of REBOA in the field environment may be on the horizon, however, for now its implementation to control traumatic hemorrhage is still in its infancy and the risk–benefit of placing these in the most skilled hands (much less in undertrained personnel or in the prehospital setting) has not been determined.⁵⁴

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