EVTM in Resuscitation Workflows
Type
ReinforcementConfidence
78%
Created
Mar 27, 2026
Evidence
2 sources
Rationale
Both articles are relevant to this section but at a reinforcement rather than modification level. Article 1 (Rossaint 2023, European trauma coagulopathy guideline, 6th edition) directly supports the Arrival/DCR row's emphasis on coagulopathy correction and massive transfusion, and its inclusion addresses the geographic guideline balance requirement — the existing section relied exclusively on US-oriented references (Spahn, Bulger) for resuscitation principles. It is added both in the table row and in the Key workflow rule paragraph. Article 2 (Cralley 2026, Zone I REBOA vs resuscitative thoracotomy registry) is already represented in the chapter under a different suffix key (cralley2026 through cralley2026-f); the new suffix Cralley AL et al. Zone 1 Endovascular Balloon Occlusion of the Aorta vs Resuscitative Thoracotomy for Patient Resuscitation After Severe Hemorrhagic Shock. JAMA Surg. 2026. PMID: 36542395. is used as instructed. Its registry finding — that patient selection and speed to definitive control drive outcomes — directly reinforces the 'bridge maneuver only if a rapid path to definitive control exists' principle and is integrated into both the REBOA table row and the Key workflow rule paragraph. No existing content was removed or reorganized. Citation density was kept consistent with the original section (one to two citations per claim). The REBOA abbreviation expansion is preserved on its first appearance in the table; subsequent uses correctly use the abbreviation alone. CTA is similarly used as an abbreviation after its first expansion earlier in the chapter.
Evidence
Content Changes
<!-- type: algorithm --> **Table 16.2. Endovascular trauma management (EVTM) Resuscitation Workflow (Physiology-First, Time-to-Control)** [@trauma2016-endovascular] | **Phase** | **Action** | **Operational detail** | | --- | --- | --- | | Arrival | Activate trauma + DCR | Early massive transfusion pathway; prevent hypothermia; correct coagulopathy. [@spahn2019] [@rossaint2023-d] | | Arrival | Obtain access | Femoral arterial + venous access early when noncompressible torso hemorrhage (NCTH) is possible. [@bulger2019] | | Unstable + suspected NCTH | Bridge maneuver | resuscitative endovascular balloon occlusion of the aorta (REBOA)REBOA (Zone I or III) only if a rapid path to definitive control exists. [@bulger2019] [@cralley2026-g] | | Transient responder | Rapid imaging | computed tomography angiography (CTA)CTA when hemodynamics allow to localize bleeding and plan endovascular vs open. | | Definitive hemorrhage control | Endovascular | Embolization for pelvic/solid organ bleeding; covered stent for junctional arterial disruption. [@coccolini2017-wses] [@markov2011] | | Definitive hemorrhage control | Open + endovascular | Hybrid OR: laparotomy/packing + angio/embolization/stent as needed. [@wses2018] | | Post-control | Transition to critical care | Occlusion deflation plan, metabolic management, limb/renal monitoring; staged definitive repair as physiology normalizes. [@bulger2019] | **Key workflow rule** REBOA and other EVTM tools are **not definitive therapy**; they are time-buying interventions that must shorten the interval to hemostasis, not prolong it. [@bulger2019] [@morrison2014] Registry data comparing Zone I REBOA with resuscitative thoracotomy in severe hemorrhagic shock suggest that patient selection and speed to definitive hemorrhage control remain the dominant determinants of outcome [@cralley2026-g], reinforcing the physiology-first triage logic embedded in this workflow. European damage-control resuscitation guidelines similarly emphasize early correction of coagulopathy and goal-directed transfusion as the systemic foundation upon which all EVTM interventions depend [@rossaint2023-d]. Cross-reference: [[Damage Control Surgery]] and [[Massive Transfusion]]. [@spahn2019]