AAJT for REBOA NOW!

At the Special Operations Medical Association Scientific Assembly this month the AAJT was shown in the REBOA algorithm for a number of special operations units. It was often placed as a recovery option if REBOA fails. However, several of the studies presented at the Military Health System Research Symposium (MHSRS) in August of last year that showed equivalency between the Abdominal Aortic and Junctional Tourniquet (AAJT) and REBOA (Zone 3) have now been published. It is a safe intervention and can be applied at the point of wounding by combat medics and first responders. Instead of a rescue intervention when REBOA fails, perhaps it should be the initial intervention to allow patients to have a chance to make it to a doctor to have REBOA attempted.

Resuscitative Endovascular Balloon Occlusion of the Aorta or REBOA is an intervention that has some dramatic physiologic effects in patients experiencing shock. While the full physiologic effects are still being studied, there are some amazing findings being reported. Recently a traumatic arrest from hemorrhage loss was recovered using REBOA. The AAJT applied externally is equivalent to this intervention! The AAJT can be applied in 45 seconds by any first responder and immediately achieve the physiological advantages of REBOA near the point of wounding. 

The significance of this is remarkable. The expense of one of the most popular REBOA kits is just under $2000 and requires a physician to place. Recently the American College of Surgeons and the American College of Emergency Physicians recommend only physicians with advance training in the procedure should attempt it. It is safest when ultrasound guidance is used. It holds similar risks to a cardiac catheterization. The AAJT costs just over $500 and can be placed by anyone. No knowledge of the anatomy is required nor is any adjunct imaging required. It does not involve any invasive aspect to utilize the device. 

REBOA can be life-saving in trauma patients. Now there are data which show an externally applied device, already approved by the FDA, is equivalent to this intervention. It is safe and can be applied by any basic EMT or paramedic. It costs less than a quarter of REBOA.

Dr. Rall’s, with 59thMed Wing, research concluded that both the AAJT and Zone 3 REBOA were equivalent in cardiac output, systemic vascular resistance and mean arterial pressure. There were also no differences found in SpO2 and the PaO2/FiO2 ratio. If the two interventions show the same survival, hemostatic, hemodynamic and metabolic profiles as the multiple studies presented showed, why would you not use the lesser invasive, safer, less expensive and quicker alternative? 

Additionally, the Institute for Surgical Research presented 3 studies at MHSRS in August showing that the application of the AAJT held no additional risks of ischemia, systemic metabolic responses, tissue inflammatory responses or end organ effects when compared to REBOA. In essence, the physiological risks of the procedure are the same, while there is inherently less risk in the application of the AAJT to the risks of application of REBOA. 

Dr. Rall’s paper showing the AAJT used in Cardiopulmonary Resuscitation following Traumatic Cardiac Arrest has published as well. The PubMed link is: https://www.ncbi.nlm.nih.gov/pubmed/28885969 Traumatic Cardiac Arrest is a distinctly difficult problem because standard CPR is simply ineffective. The 59thMedical Wing study showed that in a traumatic cardiac arrest model precipitated by Class IV hemorrhage, that remained in arrest for 3 minutes before resuscitation was started, the AAJT improved outcomes. It wasn’t a subtle improvement. A Kaplan-Meier survival analysis showed a greater than 80% survival with the AAJT application. Hemodynamically, carotid blood flow and carotid blood pressure increased with AAJT application. This is simply amazing! We have never seen survival rates like this for traumatic cardiac arrest.

The AAJT is the only junctional tourniquet to have saved life in upper and lower junctional bleeding. It is the only tourniquet shown to not fail due to collateral flow. It is the only truncal tourniquet approved by the FDA and the only device available approved to externally treat pelvic bleeding. Now its equivalency with REBOA has been demonstrated by multiple independent researchers. It is an intervention that can be safely applied by prehospital providers. 

The AAJT and REBOA equivalency holds exciting new possibilities for treating trauma patients. Now in addition to being known as the best junctional tourniquet and only truncal tourniquet available it may also deserve the name, the Resuscitation Tourniquet?. Instead of being a rescue measure when REBOA fails, perhaps it should be the first intervention to keep the patient alive until REBOA can be attempted.