Aortic Occlusion (AO) Procedure Notes: REBOA or Resuscitative Thoracotomy Mechanism of Injury (select all that apply) Insertion site: Left Right POI Vitals CPR in progress upon arrival Type of Injury (select all that apply) Presence of signs of life (select all that apply) Pericardium Palpable pulse Organized cardiac activity on ultrasound Organized cardiac activity on monitor Negative (select sites that were positive) Pneumothorax Right chest Right chest Left chest Head Mediastinal Injury RUQ 1st HR 1st SBP 1st GCS SBP Temp Total inflation time Patient Last Name First Name Last 4 SS# Date/time of Injury Age F M Gender Date/time of arrival to AO MTF No Yes 1st MTF from POI? Type of MTF Austere surgical team Role 2 FRST/FST Role 3 Where was balloon deployed? Inflation technique Zone I (Origin of left subclavian artery to the celiac artery) Complications (select all that apply) Distal pulse palpation prior to insertion Yes No Was hemodynamics improved with AO? Yes No Volume required to inflate balloon cc Other complications Device malfunctions Full Duration of AO (by balloon inflation or clamp time, in minutes): Zone III (Lowest renal artery to the aortic bifurcation) Additional AAR comments, suggestions, lessons learned can be emailed to: [email protected] Comments Body region (select all that apply) Neck Mediastinum Blunt Penetrating Pelvis Upper limb(s) Lower limb(s) Burn Other (specify) Abdomen Mounted IED Blast Vehicle crash Other (specify) GSW Dismounted IED Assessment HR GCS No Prehospital CPR required Yes No Yes Total duration of CPR (prehospital & hospital, in minutes) (E) FAST ultrasound results Left chest LUQ Pelvis CRX results Negative (select all positive CXR results that apply) L R L R Hemothorax Chest tube output Left Right cc cc Chest tube not placed AO Initiation No Was active CPR ongoing during initial AO attempt? Yes REBOA Open Provider preference REBOA contraindicated Thoracotomy not indicated Why was this type of AO selected? (select all that apply) REBOA technical features 18 Ga 5 Fr 4 Fr Initial catheter diameter size: 7 Fr No Was successful AO achieved? Yes Was initial catheter upsized? Yes No Initial labs Hgb (mg/dL) INR Base deficit +/- pH Lactate (mg/dL) REBOA supplies not available Not trained in REBOA final size= Common Femoral Other Partial Intermittent Deflation technique Gradual Full Date/time of REBOA sheath removal GCS HR SBP Immediate post inflation vital signs Vessel injuries (aortic dissection, rupture, perforation) AO technique issue Death Renal failure Extremity ischemia Infection Amputation secondary to REBOA use Hematoma Pulmonary embolism Stenosis DVT Arteriovenous fistula Need for arterial bypass Pseudoaneurysm Dissection at insertion site Need for patch angioplasty 24 Apr 2020, version 2.0 Complete all items that apply. Include in Patient's Medical Record. Upload into TMDS. Leave blank unknown or unavailable items. Note time in hh:mm format. Date/time of AO initiation

Aortic Occlusion (AO) Procedure Notes: REBOA or ... · 4/24/2020 · Aortic Occlusion (AO) Procedure Notes V2.0, 24 Apr 2020 Author: Cynthia Kurkowski Subject: Aortic Occlusion $AO$

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$Page 1: Aortic Occlusion (AO) Procedure Notes: REBOA or ... · 4/24/2020 · Aortic Occlusion (AO) Procedure Notes V2.0, 24 Apr 2020 Author: Cynthia Kurkowski Subject: Aortic Occlusion $AO$$

Aortic Occlusion (AO) Procedure Notes: REBOA or Resuscitative Thoracotomy

Mechanism of Injury (select all that apply)

Insertion site: LeftRight

POI Vitals

CPR in progress upon arrival

Type of Injury (select all that apply)

Presence of signs of life (select all that apply)

Pericardium

Palpable pulse Organized cardiac activity on ultrasoundOrganized cardiac activity on monitor

Negative (select sites that were positive)

PneumothoraxRight chest

Right chest Left chest Head

Mediastinal InjuryRUQ

1st HR 1st SBP 1st GCS

SBP Temp

Total inflation time

Patient Last Name First Name Last 4 SS# Date/time of InjuryAge FMGender

Date/time of arrival to AO MTF NoYes1st MTF from POI? Type of MTF Austere surgical team Role 2 FRST/FST Role 3

Where was balloon deployed?

Inflation technique

Zone I (Origin of left subclavian artery to the celiac artery)

Complications (select all that apply)

Distal pulse palpation prior to insertion Yes No

Was hemodynamics improved with AO? Yes No

Volume required to inflate balloon cc

Other complications

Device malfunctions

Full

Duration of AO (by balloon inflation or clamp time, in minutes):

Zone III (Lowest renal artery to the aortic bifurcation)

Additional AAR comments, suggestions, lessons learned can be emailed to: [email protected]

Comments

Body region (select all that apply) Neck Mediastinum

BluntPenetrating

Pelvis Upper limb(s) Lower limb(s)

Burn Other (specify)

Abdomen

Mounted IEDBlast Vehicle crash Other (specify)GSW Dismounted IED

Assessment HR GCS

NoPrehospital CPR required Yes

NoYes Total duration of CPR (prehospital & hospital, in minutes)

(E) FAST ultrasound results

Left chest LUQ Pelvis

CRX results Negative (select all positive CXR results that apply)

LR LRHemothorax

Chest tube output LeftRight cc cc Chest tube not placed

AO Initiation NoWas active CPR ongoing during initial AO attempt? YesREBOAOpen

Provider preference REBOA contraindicated Thoracotomy not indicatedWhy was this type of AO selected? (select all that apply)

REBOA technical features

18 Ga 5 Fr4 Fr

Initial catheter diameter size:

7 Fr

NoWas successful AO achieved? Yes

Was initial catheter upsized? Yes No

Initial labs Hgb (mg/dL) INR Base deficit +/-pH Lactate (mg/dL)

REBOA supplies not available Not trained in REBOA

final size=

Common Femoral Other

Partial Intermittent Deflation technique GradualFull

Date/time of REBOA sheath removal

GCSHR SBP

Immediate post inflation vital signs

Vessel injuries (aortic dissection, rupture, perforation)

AO technique issue

Death Renal failure

Extremity ischemia Infection

Amputation secondary to REBOA use Hematoma

Pulmonary embolism Stenosis

DVT Arteriovenous fistula

Need for arterial bypass

Pseudoaneurysm

Dissection at insertion site

Need for patch angioplasty

24 Apr 2020, version 2.0

Complete all items that apply. Include in Patient's Medical Record. Upload into TMDS. Leave blank unknown or unavailable items. Note time in hh:mm format.

Date/time of AO initiation

mailto:[email protected]