Update Course Rewind: REBOA use in Pediatric Trauma 2024

GlobalcastMD, along with Cincinnati Children's Hospital sharing knowledge to improve child health around the globe. Hello Pediatric Surgery family, I'm Lizzie Lee from Cincinnati Children's Hospital Medical Center. Our 12th Annual Update Course in Pediatric Surgery was held this past August. In this video series, we will recap the sessions and share the main highlights with you. This year we introduced a new approach to classify practice changing ideas at our update course. Presentations now fall into three categories: green circles for established practices, blue squares for promising newer practices and black diamonds for early adapter practices only. In this video, we are talking about REBOA, resuscitative endovascular balloon aortic occlusion, in pediatric trauma patients with Doctors Reagan Williams and Katie Russell. This topic falls into two categories, both black diamond and blue square, both unproven and newer practices. 16 year old shoots herself in the abdomen while cleaning her rifle. She is hypotensive and near arrest despite massive transfusion. What are you going to do? According to our audience poll, 50% would do laparotomy as the next step. 23% chose REBOA, resuscitative endovascular balloon aortic occlusion. Here's the data, it can be used in children. It's not super effective. We don't do a lot of this in a pediatric hospital and to do it very quickly in a patient population that you don't do it in very often is very difficult. But you can do it if you have that at your center and you're good at it. There is no right answer for this specific case, but most of the pediatric surgeons prefer to do laparotomy. So let's talk about the basics of REBOA. REBOA is a procedure to control bleeding in shock or traumatic cardiac arrest. A catheter is inserted with a balloon through the femoral artery into the aorta. Then the balloon is inflated to stop blood flow, which buys time for surgical intervention and can improve survival. The things that you really need to think about for this are two things. The Western Trauma Association's pediatric emergency resuscitative thoracotomy algorithm shows when to do thoracotomy. REBOA is often compared to resuscitative thoracotomy since both techniques occlude the aorta. Thoracotomy opens the chest surgically in the ER to gain rapid access to the heart, control the source of bleeding, and control the aorta. So this would be the patient to do it if you could not get them to the operating room to actually control the source of bleeding. The second is the adult version of damage control therapy for hypotension and shock. And you can see REBOA is actually under hemorrhage control. REBOA is an option in the recommendations, but it depends on what is available at your specific surgery center. The priority is that you recognize shock in this child and treat it as quickly as you can in the most controlled environment. My hospital would be in the operating room doing a laparotomy. When compared to thoracotomy, REBOA can take a few extra minutes to occlude the aorta and those few minutes can be crucial in a crashing patient. It seems to me REBOA would take longer than opening the abdomen or the chest if you're just needed to cross clamp the aorta. Does REBOA improve mortality compared to other treatment options? It looks some sort of survival advantage in adults, but also those patients were not as sick if you look at the main trial. So there isn't a clear survival advantage for using REBOA even on the adult side, so certainly not over to the kid side. In summary, while REBOA can be used in kids, it is rarely performed in pediatric hospitals, making rapid application challenging, and there was no clear survival advantage for using REBOA in adults. The Western Trauma Association's algorithm is a very helpful guideline for when to use resuscitative thoracotomy. Most surgeons favor laparotomy as the preferred option for quickly treating shock in a controlled environment. GlobalcastMD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.