323 Virtual Reality Simulation Can Help Prepare Emergency Physicians for REBOA

Abstract

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is emerging as a bridge to hemostasis in patients with exsanguinating hemorrhage below the diaphragm, as well as a means to increase cerebral and coronary perfusion in patients arriving in arrest. This procedure is currently used in a small number of tertiary trauma centers by acute care surgeons (ACS) in the United States, and internationally by emergency medicine (EM) providers both in the ED and in the field. Virtual Reality Simulation (VRS) is a well-established means of endovascular skills training for REBOA. We hypothesize that EM providers can learn the concepts and skill required for REBOA using VRS. EM trainees in ACGME-approved critical care fellowships at one institution received didactic and instructional sessions on REBOA. The subjects performed the procedure 6 times. Subjects were excluded if they had taken a similar endovascular training course or had performed the procedure in the clinical setting. Performance metrics were measured on a Likert scale, and included procedural time; accurate placement of guide wire, sheath, and balloon; correct sequence of steps; economy of motion; and safe use of endovascular tools. A pre- and post-course test and questionnaire were completed by each subject. Analysis included simple linear regression and the Student’s t test. A p-value below 0.05 was considered statistically significant. Ten subjects, with a mean PGY level of 4.6 years (SD±0.5) participated in the study. No correlation with task times was observed with any confounder studied including previous endovascular training or experience, number of central and arterial lines placed recently, or number of intra-aortic balloon pumps placed in training. Procedural task times improved from a mean of 218±19 to 106±15 seconds with a mean difference of 112 seconds, indicating the task time improvement from Trial 1 to Trial 6 was significantly different from 0 (p < 0.001). There was significant improvement in comprehension and knowledge between the pre-test and post-test, as their average performance improved from 74.3 ± 13.6% to 96.4 ± 5.0% (p<0.001). Significant improvements in procedural time and knowledge can be achieved by emergency physicians based on VRS. Advances in technology will decrease the tools and steps required for REBOA, and ultimately decrease the time to occlusion for all providers. Despite these encouraging results and regardless of advances in equipment, successful REBOA utilization will be contingent on patient selection and common femoral artery access which may not be possible without operative exposure. These areas should become a focus of further training.