Resuscitative endovascular balloon occlusion of the aorta (REBOA) is most commonly used to manage non-compressible torso hemorrhage. It is also emerging as a promising treatment for non-traumatic refractory cardiac arrest. Aortic occlusion during chest compressions increases cardio-cerebral perfusion, increasing the potential for sustained return of spontaneous circulation (ROSC) or serving as a bridge to extracorporeal cardiopulmonary resuscitation (ECPR). Optimal patient selection and post-ROSC management in such cases is uncertain and not well reported in the literature. We present a case of non-traumatic out-of-hospital cardiac arrest in which REBOA was placed in the emergency department with subsequent ROSC. Transesophageal echocardiography was used to guide post-ROSC REBOA management and balloon deflation.

Conventional treatment of out-of-hospital cardiac arrest (OHCA) involves delivering high-quality CPR, rapid defibrillation when indicated, advanced airway placement, and pharmacological interventions. Within the last 40 years, extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a potential therapy for carefully selected patients whose arrest is refractory to conventional treatments. In this population, ECPR provides a survival benefit compared to standard care as described above [1]. ECPR is costly, requires technical expertise, is logistically challenging, and is unavailable to most OHCA patients [[2], [3], [4]]. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was developed as a technique for treating patients suffering from hemorrhagic shock due to non-compressible truncal hemorrhage. Occlusion of the thoracic aorta during chest compressions increases central perfusion and is associated with increased end tidal carbon dioxide, an important measure of resuscitation quality [5,6]. REBOA may lead to sustained ROSC or can serve as a bridge to ECPR in cases of refractory cardiac arrest. While animal data, limited case studies, and a recent feasibility trial suggest that REBOA may also be beneficial in managing refractory cardiac arrest by producing increased coronary and cerebral perfusion, the approach to managing shock and preventing re-arrest after balloon deflation is not well described [[7], [8], [9], [10], [11], [12]]. We present a case of refractory OHCA in which REBOA was used in the emergency department (ED) with post-ROSC management guided by transesophageal echocardiography (TEE).

A 40-year-old male was found pulseless shortly after receiving intramuscular haloperidol for acute agitation at a psychiatric facility. Staff began CPR and a single shock was delivered to the patient with an automated external defibrillator. When a basic life support crew arrived, pulseless electrical activity (PEA) was the initial rhythm. Advanced life support then arrived and within 9 min a supraglottic device had been placed and the first dose of epinephrine had been administered. The

REBOA is a potential tool for improving coronary and cerebral perfusion and promoting ROSC in refractory non-traumatic cardiac arrest. Several case series have demonstrated the feasibility of prehospital placement by physicians, resulting in ROSC after prolonged periods of CPR [[8], [9], [10], [11], [12]]. It still remains unknown if REBOA can improve neurologically-intact survival from cardiac arrest. The best outcomes are likely to occur in patients who meet ECPR criteria before irreversible

Christopher Kelly: Conceptualization, Investigation, Writing – original draft, Writing – review & editing. H. Hill Stoecklein: Writing – original draft, Writing – review & editing. Graham Brant-Zawadzki: Writing – original draft, Writing – review & editing. Guillaume Hoareau: Writing – original draft, Writing – review & editing. James Daley: Writing – original draft, Writing – review & editing. Craig Selzman: Writing – original draft, Writing – review & editing. Scott Youngquist:

There are more references available in the full text version of this article.

© 2022 Elsevier Inc. All rights reserved.