Junctional hemorrhage, which refers to a hemorrhage that occurs at the junction of an extremity with the torso at an anatomic location, is caused by abdominopelvic, thoracic and lower cervical injuries [
1]. It is a primary cause of death due to trauma because of the poor effectiveness in controlling bleeding with traditional methods, especially in the pre-hospital settings [
2]. A study on U.S. combat fatalities showed that, between 2001 and 2011, 17.5% (171/976) of potentially preventable pre-hospital deaths were caused by junctional hemorrhage [
3]. Another study showed a mortality rate of 45% among patients with junctional hemorrhage in the pre-hospital setting [
4].
As a traditional hemostatic method, compression with standard gauze is widely used in many pre-hospital and transportation settings; however, a low survival rate of 12–55% has been shown in previous studies [
5‐
9]. Recent studies have reported applying new hemostatic devices, such as AAJTTM, CRoCTM, JETTTM, SAM-JTTM to treat junctional hemorrhage in the pre-hospital and transportation settings [
10‐
13]. However, a previous study that evaluated their effectiveness showed poor performance of these devices in terms of application time and pulse elimination[
14]. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was initial proposed by Hughes, and first used for injured soldiers in the Korean war [
1]. As a minimally invasive procedure, progressively growing interest in REBOA has arisen, as it can be used for temporary hemostasis as an emerging strategy in many clinical settings [
15,
16]. REBOA has been shown to provide promising support for life-threating hemorrhage patients with less mortality. A study showed superior survival outcomes with REBOA compared to resuscitative thoracotomy with aortic cross-clamping in patients with severe hemorrhagic shock (mortality rate, 62.5% vs. 16.7%,
p < 0.001) [
16]. A retrospective study on trauma management also showed that REBOA was significantly associated with lower mortality (adjusted odds ratio of survival, 7.4; 95% CI, 1.1–51.1) [
17]. However, the effectiveness of REBOA in the pre-hospital setting is still controversial as it largely depends on the accuracy and punctuality of placing the balloon. A study showed that 6 of 19 REBOA attempts (32%) in trauma patients with exsanguinating pelvic hemorrhage failed in the pre-hospital setting, mainly due to inaccuracies in locating the bleeding site or placing the balloon [
18]. Consequently, we assume that the aid of an imaging technique could be beneficial for the use of REBOA.
Using fluoroscopy or CT to guide the process of REBOA is popular among clinical patients [
11,
12], yet these imaging instruments are not feasible in the pre-hospital setting due to their large size and inconvenient operation. However, the usage of portable ultrasound in the pre-hospital setting has gained increasing attention during the past decade [
19]. Although many studies have shown the effectiveness of using ultrasound to evaluate bleeding after intraperitoneal trauma, to diagnose and grade abdominal organ trauma, and to guide the injection of hemostatic agents [
14‐
16], no previous study has revealed the effects of using potable ultrasound to guide REBOA for junctional hemorrhage. In this study, we explored the effectiveness of applying portable ultrasound to guide REBOA for iliac artery hemostasis in the first aid pre-hospital setting.