Extracorporeal life support in pulmonary failure after trauma

Adult ECMO in the En Route Care Environment: Overview and Practical Considerations of Managing ECMO Patients During Transport

Purpose of Review

The authors’ experience as a part of the U.S. Military ECMO program to include the challenges and successes learned from over 200 transports via ground and air is key to the expertise provided to this article. We review the topic of ECMO transport from a historical context in addition to current capabilities and significant developments in transport logistics, special patient populations, complications, and our own observations and approaches to include team complement and feasibility.

Recent Findings

ECMO has become an increasingly used resource during the last couple of decades with considerable increase during the Influenza pandemic of 2009 and the current COVID-19 pandemic. This has led to a corresponding increase in the air and ground transport of ECMO patients.

Summary

As centralized ECMO resources become available at health care centers, the need for safe and effective transport of patients on ECMO presents an opportunity for ongoing evaluation and development of safe practices.

Outcomes in trauma patients undergoing veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome

BACKGROUND

The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) remains controversial in trauma patients with acute respiratory distress syndrome (ARDS). Here, we aimed to investigate the therapeutic benefits of VV ECMO and the factors affecting patient outcomes.

METHODS

From 2017 to 2019, 21/1938 trauma patients (median age: 47 years; 18 men) at a level I trauma center received VV ECMO for post-traumatic ARDS. Demographic, injury-specific, ECMO, and outcome data were prospectively collected and retrospectively reviewed to analyze the factors affecting hospital mortality and ECMO results.

RESULTS

19 patients (90.5%) were successfully weaned off ECMO; 16 patients (76.2%) survived to discharge. In univariate analysis, there was a significant difference in survival between the groups with a Trauma and Injury Severity Score (TRISS) ⩾0.5 and TRISS <0.5 (p = 0.05). The area under the receiver operating characteristic curve (AUC) for both TRISS and Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) scores for death was 0.78. In those who failed ECMO weaning, the AUCs of the TRISS and RESP scores were 0.90 and 0.80, respectively.

CONCLUSIONS

In patients with ARDS caused by severe trauma and supported by VV ECMO, survival is associated with TRISS; TRISS and RESP scores may be predictive of mortality and failure in ECMO weaning.

Initial Experiences of Extracorporeal Membrane Oxygenation for Trauma Patients at a Single Regional Trauma Center in South Korea

Purpose For severe lung injuries or acute respiratory distress syndrome that occurs during critical care due to trauma, extracorporeal membrane oxygenation (ECMO) may be used as a salvage treatment. This study aimed to describe the experiences at a single center with the use of ECMO in trauma patients. Methods We enrolled a total of 25 trauma patients who were treated with ECMO between January 2015 and December 2019 at a regional trauma center. We analyzed and compared patients’ characteristics between survivors and non-survivors through a medical chart review. We also compared the characteristics of patients between direct and indirect lung injury groups. Results The mean age of the 25 patients was 45.9±19.5 years, and 19 patients (76.0%) were male. The mean Injury Severity Score was 26.1±10.1. Ten patients (40.0%) had an Abbreviated Injury Scale (AIS) 3 score of 4, and six patients (24.0%) had an AIS 3 score of 5. There were 19 cases (76.6%) of direct lung injury. The mortality rate was 60.0% (n=15). Sixteen patients (64.0%) received a loading dose of heparin for the initiation of ECMO. There was no significant difference in heparin use between the survivors and non-survivors (70% in survivors vs. 60% in non-survivors, p=0.691). When comparing the direct and indirect lung injury groups, there were no significant differences in variables other than age and ECMO onset time. Conclusions If more evidence is gathered, risk factors and indications will be identified and we expect that more trauma patients will receive appropriate treatment with ECMO.

Extracorporeal Life Support (ECLS): A Review and Focus on Considerations for COVID-19

ABSTRACT

Extracorporeal life support (ECLS) is a support modality for patients with severe acute respiratory distress syndrome (ARDS) who have failed conventional treatments including low tidal volume ventilation, prone positioning, and neuromuscular blockade. In addition, ECLS can be used for hemodynamic support for patients with cardiogenic shock or following cardiac arrest. Injured patients may also require ECLS support for ARDS and other indications. We review the use of ECLS for ARDS patients, trauma patients, cardiogenic shock patients, and post-cardiac arrest patients. We then describe how these principles are applied in the management of the novel coronavirus disease 2019 pandemic. Indications, predictors, procedural considerations, and post-cannulation management strategies are discussed.

Outcomes of Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome Following Traumatic Injury: A Propensity-Matched Analysis

Supplemental Digital Content is available in the text.

OBJECTIVES:

The purpose of this study is to evaluate the overall occurrence of inhospital mortality in trauma patients who were placed on extracorporeal membrane oxygenation following the complication of the acute respiratory distress syndrome.

DESIGN:

Observational cohort study.

SETTING:

The data of all patients who were traumatically injured and developed the complication of acute respiratory distress syndrome were accessed from the Trauma Quality Improvement Program database from the calendar years of 2013 to 2016.

PATIENTS:

Patients 16 years old and less than 90 years old were included in the study. Variables included patient demography, Injury Severity Score, Glasgow Coma Scale score, Abbreviated Injury Scale score, and outcomes.

INTERVENTIONS:

Extracorporeal membrane oxygenation.

MEASUREMENTS AND MAIN RESULTS:

Propensity-matched analysis was performed between two groups: patients placed on extracorporeal membrane oxygenation and patients placed on conventional mode of ventilation. The primary outcome was inhospital mortality. Out of 6,121 patients who developed acute respiratory distress syndrome, 118 patients (1.93%) were placed on extracorporeal membrane oxygenation. The pair matched analysis showed significant difference between the two groups (extracorporeal membrane oxygenation vs conventional mode of ventilation) for overall inhospital mortality (35.6% vs 14.4%; p < 0.001). There were significant differences found between the two groups for the median hospital length of stay (41 [35–49] vs 27 [24–33]), ICU days (35 [30–41] vs 19 [17–24]), and ventilator days (30 [27–34] vs 15 [13–18]). All p values are less than 0.001.

CONCLUSIONS:

Approximately 2% of acute respiratory distress syndrome patients were placed on extracorporeal membrane oxygenation. The overall inhospital mortality remained high despite patients being placed on extracorporeal membrane oxygenation.

Extracorporeal support for trauma: A trauma quality improvement project (TQIP) analysis in patients with acute respiratory distress syndrome

INTRODUCTION

The use of extracorporeal membrane oxygenation (ECMO) in trauma patients with severe acute respiratory distress syndrome (ARDS) continues to evolve. The objective of this study was to perform a comparative analysis of trauma patients with ARDS who received ECMO to a propensity matched cohort of patients who underwent conventional management.

METHODS

The Trauma Quality Improvement Program (TQIP) database was queried from 2013 to 2016 for all patients with ARDS and those who received ECMO. Demographics, as well as clinical, injury, intervention, and outcome data were collected and analyzed. Patients with ARDS were divided into two groups, those who received ECMO and those who did not. A propensity score analysis was performed using the following criteria: age, gender, vital signs (HR, SBP) and GCS on admission, Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) score in several body regions. Outcomes between the groups were subsequently compared using univariate as well as Cox regression analyses. Secondary outcomes such as hospitalization (HLOS), ICU length-of-stay (LOS) and ventilation days stratified for patient demographics, timing of ECMO and anticoagulation status were compared.

RESULTS

Over the 3-year study period, 8990 patients with ARDS were identified from the TQIP registry. Following exclusion, 3680 were included in the final analysis, of which 97 (2.6%) received ECMO. On univariate analysis following matching, patients who underwent ECMO had lower overall hospital mortality (23 vs 50%, p < 0.001) with higher rates of complications (p < 0.005), including longer HLOS. In those undergoing ECMO, early initiation (<7 days) was associated with shorter HLOS, ICU LOS, and fewer ventilator days. No difference was observed between the two groups with regard to anticoagulation.

CONCLUSION

Extracorporeal membrane oxygenation use in trauma patients with ARDS may be associated with improved survival, especially for young patients with thoracic injuries, early in the course of ARDS. Anticoagulation while on circuit was not associated with increased risk of hemorrhage or mortality, even in the setting of head injuries. The mortality benefit suggested with ECMO comes at the expense of a potential increase in complication rate and prolonged hospitalization.

Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team

INTRODUCTION

The use of extracorporeal membrane oxygenation (ECMO) for the care of critically ill adult patients has increased over the past decade. It has been utilized in more austere locations, to include combat wounded. The U.S. military established the Acute Lung Rescue Team in 2005 to transport and care for patients unable to be managed by standard medical evacuation resources. In 2012, the U.S. military expanded upon this capacity, establishing an ECMO program at Brooke Army Medical Center. To maintain currency, the program treats both military and civilian patients.

MATERIALS AND METHODS

We conducted a single-center retrospective review of all patients transported by the sole U.S. military ECMO program from September 2012 to December 2019. We analyzed basic demographic data, ECMO indication, transport distance range, survival to decannulation and discharge, and programmatic growth.

RESULTS

The U.S. military ECMO team conducted 110 ECMO transports. Of these, 88 patients (80%) were transported to our facility and 81 (73.6%) were cannulated for ECMO by our team prior to transport. The primary indication for ECMO was respiratory failure (76%). The range of transport distance was 6.5 to 8,451 miles (median air transport distance = 1,328 miles, median ground transport distance = 16 miles). In patients who were cannulated remotely, survival to decannulation was 76% and survival to discharge was 73.3%.

CONCLUSIONS

Utilization of the U.S. military ECMO team has increased exponentially since January 2017. With an increased tempo of transport operations and distance of critical care transport, survival to decannulation and discharge rates exceed national benchmarks as described in ELSO published data. The ability to cannulate patients in remote locations and provide critical care transport to a military medical treatment facility has allowed the U.S. military to maintain readiness of a critical medical asset.

Single Center Experience With Veno-Venous Extracorporeal Membrane Oxygenation in Patients With Traumatic Brain Injury

METHODS

We retrospectively reviewed TBI patients ≥ 18 years of age treated with VV-ECMO. The primary outcome was survival to discharge. Secondary outcomes included progression of intracranial hemorrhage, bleeding complications, and episodes of oxygenator thrombosis requiring exchange. Medians and interquartile ranges were reported where appropriate.

RESULTS

13 TBI patients received VV-ECMO support during the study period. The median age was 28 years (Interquartile range (IQR) 25-37.5) and 85% were men. Median admission Glasgow coma scale was 5 (IQR 3-13.5). Median injury severity score (ISS) was 48 (IQR 33.5-66). Median pre-ECMO PaO2:FiO2 ratio was 58 (IQR 47-74.5). Five (38.4%) patients survived to discharge. Six patients (46%) received systemic A/C while on ECMO. No patient had worsening of intracranial hemorrhage on computed tomography imaging. There were two bleeding complications in patients on A/C, neither was related to TBI. Four patients required an oxygenator change; 2 in patients on A/C.

CONCLUSION

VV-ECMO appears safe with TBI. We have demonstrated that A/C can be withheld without increased complications. Traumatic brain injury should not be considered an absolute contraindication to the use of VV-ECMO for severe respiratory failure and should be decided on a case by case basis. Additional research is needed to confirm these preliminary findings.

Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome During Hemorrhagic Shock

Despite overall improvements in critical care, mortality from acute respiratory distress syndrome (ARDS) remains high. Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is used to rescue patients with severe ARDS. Although V-V ECMO can be life-saving, there are significant risks associated with this therapy. Hemorrhage is one of the most common complications. Therefore, some providers are reluctant to use V-V ECMO in patients with severe ARDS who concurrently have a high risk of bleeding or recent active hemorrhage. Several studies have been published detailing the safety of heparin-sparing or completely heparin-free anticoagulation strategies in patients on V-V ECMO. We present the cases of two patients with hemorrhagic shock and ongoing transfusion requirements who developed severe and refractory ARDS while in the operating room for hemorrhage control. After the massive bleeding was stopped, both patients were placed on V-V ECMO and were managed with minimal or no therapeutic anticoagulation for the duration of their course on V-V ECMO. Both patients required multiple operations and procedures while on V-V ECMO and there were no significant hemorrhagic complications. In conclusion, V-V ECMO can be considered for use in select patients with severe ARDS and high risk of hemorrhage, active hemorrhage, or ongoing transfusion requirements.

Venoarterial Extracorporeal Life Support Utilization in a Pediatric Trauma Patient Following a Severe Dog Mauling

According to the Centers for Disease Control and Prevention, approximately 4.5 million dog bites occur each year in the United States, and more than half of these cases affect children. An estimated 1 in 6 dog bites, representing more than 800,000 bite victims each year, requires some form of medical attention. Historically, pediatric trauma patients who suffer devastating injuries and cardiopulmonary collapse requiring heroic salvage efforts have poor outcomes. We present the first case of extracorporeal membrane oxygenation utilized in a pediatric trauma patient following a severe dog bite injury. This case is an extraordinary example of multidisciplinary care of the pediatric trauma patient. It highlights the public health burden of dog bite injuries and the scant literature on extracorporeal membrane oxygenation in pediatric trauma patients.

Successful Resuscitation Using Extracorporeal Membrane Oxygenation of 2 Patients With Severe Liver Rupture: A Case Report

Extracorporeal membrane oxygenation is a rescue treatment for respiratory or cardiac failure. Its use is limited in patients predisposed to bleeding due to heparin administration. We present 2 patients with deranged coagulation after liver rupture successfully treated by extracorporeal membrane oxygenation. One patient with cardiac arrest developed a liver laceration during resuscitation. Liver suture was performed, but acute respiratory distress syndrome (PaO2/fraction of inspired oxygen, 50) necessitated venovenous extracorporeal membrane oxygenation. The other patient suffered hemothorax, thoracic aorta dissection, and liver rupture. Liver segments VI and VII were resected. Endovascular aneurysm repair of aortic dissection and venoarterial extracorporeal membrane oxygenation were performed. Both patients survived without neurological sequelae.

Extracorporeal Membrane Oxygenation in ARDS

Extracorporeal membrane oxygenation (ECMO) has become a key tool in the management of cardiac and/or respiratory failure refractory to conventional management. Although ECMO has multiple indications, it has been widely studied for the management of acute respiratory distress syndrome in adults. ECMO provides rest and support while the damaged lungs heal. It is an invasive modality with risks of serious complications; therefore, clinicians should be vigilant during patient selection. Furthermore, users should be familiar with different components of the ECMO machinery and the management of different organ systems while patients are on the circuit. ECMO is a relatively new modality that has shown good results when used in certain circumstance, and its use is becoming more popular across the United States.

Use of ECMO support in pediatric patients with severe thoracic trauma

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been used in the non-trauma setting for over 30 years. However, the use of ECMO in trauma remains a difficult question, as the risk of bleeding must be weighed against the benefits of cardiopulmonary support.

METHODS

Retrospective review of children who sustained severe thoracic trauma (chest abbreviated injury score ≥3) and required ECMO support between 2009 and 2016.

RESULTS

Of the 425 children who experienced severe thoracic trauma, 6 (1.4%) underwent ECMO support: 67% male, median age 4.8 years, median ISS 36, median GCS 3, and overall survival 83%. The median hospital day of ECMO initiation was 2 with a median ECMO duration of 7 days. All cannulations occurred through the right neck regardless of the size of the child. Five initially had veno-venous support with 1 requiring conversion to veno-arterial (VA) support. Both children on VA support suffered devastating cerebrovascular accidents, one of which ultimately led to withdrawal of care and death. Complications in the cohort included: paraplegia (1), neurocognitive defects/dysphonia (1), infected neck hematoma (1), deep femoral venous thrombosis (1), bilateral lower extremity spasticity (1).

CONCLUSION

This small cohort supports the use of ECMO in children with severe thoracic injuries as a potentially lifesaving intervention, however, not without significant complication.

LEVEL OF EVIDENCE

IV.

Use of extracorporeal membranous oxygenation in the management of refractory trauma-related severe acute respiratory distress syndrome: a national survey of the Eastern Association for the Surgery of Trauma

Objective

To report results of a national survey of provider attitudes, observations, and opinions regarding the use of extracorporeal membranous oxygenation (ECMO) to manage severe acute respiratory distress syndrome (ARDS) in trauma patients.

Design

A survey was created to query providers on the use of ECMO in trauma, as well as general management principals related to care of the patient with refractory hypoxic respiratory failure. The survey was sent to all members of Eastern Association for the Surgery of Trauma (EAST). Once completed, the survey was returned to the University of Alabama at Birmingham and results were analyzed.

Setting/patients

Trauma patients with refractory ARDS.

Interventions

None.

Measurements and main results

Respondents were from 37 states, the District of Columbia, and Puerto Rico. 56.9% reported institutional ECMO capabilities, but only 45.2% reported using ECMO for trauma patients. Most respondents (90.2%) reported ECMO use in less than or equal to five trauma patients per year. 20.9% think there is not enough data to support its use in trauma but only 4.7% would absolutely not consider ECMO use for trauma patients. Ranking the preferred modality of treatments for refractory ARDS from most to least preferable is as follows: airway pressure release ventilation, bilevel ventilation, paralysis, prone positioning, inhaled nitric oxide, epoprostenol, high-frequency oscillatory ventilation, corticosteroids, surfactant.

Conclusions

ARDS has a high mortality among trauma patients. Despite its utility in treating severe ARDS and other pulmonary disease processes, ECMO has not been universally embraced by the trauma community. There are an increasing number of studies that suggest that ECMO is a safe and viable treatment option for trauma patients with ARDS. Based on the results of this survey, ECMO use remains limited by trauma providers that care for patients with refractory hypoxic respiratory failure and ARDS, likely due to a combination of knowledge gaps and lack of access to ECMO.

Level of evidence

Level V.

Acute Respiratory Failure

Acute respiratory distress syndrome (ARDS) is a condition affecting critically ill patients, characterized by pulmonary inflammation and defects in oxygenation due to either direct or indirect injury to the lungs. These guidelines will define the diagnosis and management of ARDS, particularly among combat casualties and patients in the deployed environment. The cornerstone of management of ARDS involves maintaining adequate oxygenation while avoiding further pulmonary injury through lung-protective ventilation. Additional strategies for advanced respiratory failure, such as prone positioning, neuromuscular blockade, and extracorporeal membrane oxygenation will be reviewed here as well. Particularly important to the care of the patient with ARDS in the deployed environment is a familiarity with the challenges and indications for transport/aeromedical evacuation.

A case report: Veno-venous extracorporeal membrane oxygenation for severe blunt thoracic trauma

Introduction

The use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in trauma patients has been controversial, but VV-ECMO plays a crucial role when the lungs are extensively damaged and when conventional management has failed. VV-ECMO provides adequate tissue oxygenation and an opportunity for lung recovery. However, VV-ECMO remains contraindicated in patients with a risk of bleeding because of systemic anticoagulation during the treatment. The most important point is controlling the bleeding from severe trauma.

Case

A 32-year-old male experienced blunt trauma due to a traffic accident. He presented with bilateral hemopneumothorax and bilateral flail chest. We performed emergency thoracotomy for active bleeding and established circulatory stability. After surgery, the oxygenation deteriorated under mechanical ventilation, so we decided to establish VV-ECMO. However, bleeding from the bilateral lung contusions increased after VV-ECMO was established, and the patient was switched to heparin-free ECMO. After conversion, we could control the bronchial bleeding, especially the lung hematomas, and the oxygenation recovered. The patient was discharged without significant complications. VV-ECMO and mechanical ventilation were stopped on days 10 and 11, respectively. He was discharged from the ICU on day 15.

Conclusion

When we consider the use of ECMO for patients with uncontrollable, severe bleeding caused by blunt trauma, it may be necessary to use a higher flow setting for heparin-free ECMO than typically used for patients without trauma to prevent thrombosis.

AAST Critical Care Committee clinical consensus: ECMO, nutrition

The American Association for the Surgery of Trauma Critical Care Committee has developed clinical consensus guides to help with practical answers based on the best evidence available. These are focused in areas in which the levels of evidence may not be that strong and are based on a combination of expert consensus and research. Overall, quality of the research is mixed, with many studies suffering from small numbers and issues with bias. The first two of these focus on the use of extracorporeal membrane oxygenation in trauma patients and nutrition for the critically ill surgical/trauma patient.

National estimates of the use and outcomes of extracorporeal membrane oxygenation after acute trauma

Background

The use of extracorporeal membrane oxygenation (ECMO) as salvage therapy for patients with severe acute respiratory distress syndrome is gaining greater acceptance among trauma intensivists. The objective of this study was to review ECMO usage in trauma patients in the USA.

Methods

The National Inpatient Sample (NIS) from years 2002 to 2012 was queried for patients aged 15 and older treated with ECMO who had one or more acute traumatic injuries as defined by the International Diagnostic Codes, Ninth Edition (ICD-9). The primary outcomes of interest were incidence of ECMO and overall inpatient mortality.

Results

A total of 1347 patients were identified in the NIS database who had both ECMO performed and ICD-9 codes consistent with trauma. Patients were predominantly aged 15 to 29 years (31.4%) and were male (65.5%). The incidence of ECMO for patients after traumatic injuries has increased 66-fold during the 10-year period. In-hospital mortality was 48.0% overall, with a decreasing trend during the study period that approached statistical significance (p=0.06).

Discussion

Although ECMO use in patients in the post-trauma setting remains controversial, there is an increasing trend to use ECMO nationwide, suggesting an increasing acceptance and/or increased availability at trauma centers. Given the decrease in mortality during the study period, ECMO as a salvage method in trauma patients remains a potentially viable option. Evaluation in a prospective manner may clarify risks and benefits.

Level of evidence

Level IV, epidemiological.

Intraoperative Venovenous Extracorporeal Membrane Oxygenation as Rescue for a Patient With an Inhalational Burn and Iatrogenic Upper Airway Injury: A Case Report

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a well-established alternative oxygenation method for critically ill patients. A 58-year-old male was transferred to our level 1 trauma and burn center after sustaining an inhalational injury from a carburetor explosion, with subsequent iatrogenic tracheal injury and emergent cricothyrotomy before arrival. During attempted surgical airway stabilization, our ability to ventilate and oxygenate was compromised. Intraoperative VV-ECMO enabled rescue from severe hypoxemia and subsequent recovery without lasting neurologic sequelae. This case highlights the utility of VV-ECMO for acute intraoperative rescue.

Craniectomy and Traumatic Brain Injury in Children on Extracorporeal Membrane Oxygenation Support

Severe trauma may cause refractory life-threatening respiratory failure requiring extracorporeal membrane oxygenation (ECMO). Concurrent traumatic brain injury, however, complicates the use of ECMO because of the major risk of intracranial bleeding with systemic anticoagulation. Craniotomy and/or craniectomy for hematoma evacuation during ECMO are extremely high-risk procedures secondary to ongoing anticoagulation, and there are only a few such case reports in the literature. We present the case of a child with multiple thoracic injuries and life-threatening respiratory failure supported on ECMO. She developed an intracranial hemorrhage while systemically heparinized that required emergent decannulation and bedside craniectomy for hematoma extraction. She survived with an excellent neurologic outcome. We also review the relevant literature regarding the use of ECMO in patients with polytrauma and the occurrence of craniectomy on extracorporeal support, with a focus on pediatric publications. Patients with polytrauma with brain injury can be supported on ECMO, but extreme precaution must be taken regarding anticoagulation. The intracranial complications of ECMO in this population are not infrequent, but our case report and review of the literature suggest that neurosurgical intervention should be considered in life-threatening conditions when no other alternatives are available.

Veno-Venous Extracorporeal Membrane Oxygenation (VV ECMO) for Acute Respiratory Failure Following Injury: Outcomes in a High-Volume Adult Trauma Center with a Dedicated Unit for VV ECMO

INTRODUCTION

The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) has increased over the past decade. The purpose of this study was to evaluate outcomes in adult trauma patients requiring VV ECMO.

METHODS

Data were collected on adult trauma patients admitted between January 1, 2015, and November 1, 2016. Demographics, injury-specific data, ECMO data, and survival to discharge were recorded. Medians [interquartile range (IQR)] were reported. A p value ≤0.05 was considered statistically significant.

RESULTS

Eighteen patients required VV ECMO during the study period. Median age was 28.5 years (IQR 24-43). Median injury severity score (ISS) was 27 (IQR 21-41); median PaO₂/FiO₂ (P/F) prior to ECMO cannulation was 61 (IQR 50-70). Median time from injury to cannulation was 3 (IQR 0-6) days. Median duration of ECMO was 266 (IQR 177-379) hours. Survival to discharge was 78%. Survivors had a significantly higher ISS (p = 0.03), longer intensive care unit length of stay (ICU LOS) (p < 0.0004), hospital LOS (p < 0.000004), and time on the ventilator (p < 0.0003). Median time of injury to cannulation was significantly longer in patients who survived to discharge (p = 0.01). There was no difference in P/F ratio prior to cannulation (p = ns).

CONCLUSION

We have demonstrated improved outcome of patients requiring VV ECMO following injury compared to historical data. Although shorter time from injury to cannulation for VV ECMO was associated with death, select patients who meet criteria for VV ECMO early following injury should be referred/transferred to a tertiary care facility that specializes in trauma and ECMO care.

Extracorporeal membrane oxygenation in trauma: A single institution experience and review of the literature

INTRODUCTION:

Limited options exist for cardiovascular support of the trauma patient in extremis. This patient population offers challenges that are often considered insurmountable. This article identifies a heterogeneous group of trauma patients in extremis who may benefit from extracorporeal membrane oxygenation.

METHODS:

Data were sourced from the medical records of all patients placed on extracorporeal membrane oxygenation following trauma at a Level I Trauma Center between 1 December 2016 and 1 December 2017.

RESULTS:

All patients were male (N = 7), mostly with blunt injuries (n = 5), with an average age of 41 years and with an average Injury Severity Scores of 33 (median = 34). Two out of seven patients survived (28.5%). Survivors tended to have a longer duration on extracorporeal membrane oxygenation (13.5 vs 3.8 days), had extracorporeal membrane oxygenation initiated later (15 vs 7.8 days), and had suffered a blunt injury. Two patients were initiated on veno-arterial extracorporeal membrane oxygenation (both non-survivors) and five were initiated on veno-venous extracorporeal membrane oxygenation (two survivors, three non-survivors). Five patients were heparinized immediately (one survivor, four non-survivors), and two patients were heparinized after clotting was noted in the circuit (one survivor, one non-survivor). Three of the seven (42.8%) patients suffered cardiac arrest either prior to, or during, the initiation of extracorporeal membrane oxygenation (all non-survivors).

DISCUSSION:

Extracorporeal membrane oxygenation use in the trauma patient in extremis is not standard; however, this article demonstrates that extracorporeal membrane oxygenation is feasible in a complex, heterogeneous patient population when treated at designated centers.

The Impact of an Advanced ECMO Program on Traumatically Injured Patients

In June 2016, an advanced extracorporeal membrane oxygenation (ECMO) program consisting of a multidisciplinary team was initiated at a large level-one trauma center. The program was created to standardize management for patients with a wide variety of pathologies, including trauma. This study evaluated the impact of the advanced ECMO program on the outcomes of traumatically injured patients undergoing ECMO. A retrospective cohort study was performed on all patients sustaining traumatic injury who required ECMO support from January 2014 to September 2017. The primary outcome was to determine survival in trauma ECMO patients in the two timeframes, before and after initiation of the advanced ECMO program. Secondary outcomes included complication rates, length of stay, ventilator usage, and ECMO days. One hundred and thirty eight patients were treated with ECMO during the study period. Of the 138 patients, 22 sustained traumatic injury. Seven patients were treated in our pre-group and 15 in our post-group. The majority of patients were treated with VV ECMO. Our post group VV ECMO extracorporeal survival rate was 64% and our survival to discharge was 55%. This study demonstrated an improvement in survival after implementation of our advanced ECMO program. The implementation of a multidisciplinary trauma ECMO team dedicated to the rescue of critically ill patients is the key for achieving excellent outcomes in the trauma population.

Early initiation of extracorporeal membrane oxygenation improves survival in adult trauma patients with severe adult respiratory distress syndrome

BACKGROUND

The use of extracorporeal membrane oxygenation (ECMO) in the trauma population has been reported to have a mortality benefit in patients with severe refractory hypoxic respiratory failure. This study compares the early initiation of ECMO for the management of severe adult respiratory distress syndrome (ARDS) versus a historical control immediately preceding the use of ECMO for trauma patients.

METHODS

A retrospective study was conducted at a single verified Level I trauma center. The study population was limited to trauma patients diagnosed with severe ARDS using the Berlin definition (PaO2/FIO2 ratio < 100). Patients managed with ECMO versus conventional ventilation (CONV) were compared. The primary outcome of interest was mortality; secondary outcomes included hospital length of stay, intensive care unit-free days, and ventilator-free days.

RESULTS

Fifteen ECMO patients managed from March 2013 to November 2014 were identified, as were 14 CONV patients managed from March 2012 to February 2013 who met the Berlin definition of severe ARDS. Data related to age, Injury Severity Scores (ISSs), admission lactic acid levels, base deficit, the number of transfused red blood cell units within the first 24 hours, and presence of severe traumatic brain injury were collected and were not statistically different between the groups. Likewise, Murray Lung Injury (MLI), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores determined at the onset of severe ARDS were not statistically different between the groups. Median hospital stay (CONV, 28.0 days [14.0-47.0]; ECMO, 43.5 days [30.0-93.0]; p = 0.15), intensive care unit-free days (CONV, 0.0 days [0.0-5.0]; ECMO, 5.0 days [0.0-7.0]; p = 0.26), and ventilator-free days (CONV, 0.0 days [0.0-10.0]; ECMO, 8.0 days [0.0-19.0]; p = 0.13) were not statistically different between the groups. Mortality in the ECMO group was significantly reduced compared with the CONV group (ECMO, 13.3%; CONV, 64%; p = 0.01). Timing from the onset of severe ARDS to ECMO intervention occurred at a mean 1.9 ± 1.4 days.

CONCLUSION

Patients who were treated with ECMO for severe ARDS had an improved mortality compared with historical controls. ECMO should be considered at the early onset of severe ARDS to improve survival.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Should Extracorporeal Membrane Oxygenation Be Offered? An International Survey

OBJECTIVES

To assess the current attitudes of extracorporeal membrane oxygenation (ECMO) program directors regarding eligibility for ECMO among children with cardiopulmonary failure.

STUDY DESIGN

Electronic cross-sectional survey of ECMO program directors at ECMO centers worldwide within the Extracorporeal Life Support Organization directory (October 2015-December 2015).

RESULTS

Of 733 eligible respondents, 226 (31%) completed the survey, 65% of whom routinely cared for pediatric patients. There was wide variability in whether respondents would offer ECMO to any of the 5 scenario patients, ranging from 31% who would offer ECMO to a child with trisomy 18 to 76% who would offer ECMO to a child with prolonged cardiac arrest and indeterminate neurologic status. Even physicians practicing the same specialty sometimes held widely divergent opinions, with 50% of pediatric intensivists stating they would offer ECMO to a child with severe developmental delay and 50% stating they would not. Factors such as quality of life and neurologic status influenced decision making and were used to support decisions for and against offering ECMO.

CONCLUSIONS

ECMO program directors vary widely in whether they would offer ECMO to various children with cardiopulmonary failure. This heterogeneity in physician decision making underscores the need for more evidence that could eventually inform interinstitutional guidelines regarding patient selection for ECMO.

Long-term extracorporeal membrane oxygenation after severe blunt traumatic lung injury in a child

Managing acute respiratory distress syndrome (ARDS) after severe blunt traumatic lung injury can be challenging. In cases where patients are refractory to conventional therapy, extracorporeal membrane oxygenation (ECMO) should be considered. In addition, the heparin-coated circuit can reduce hemorrhagic complications in patients with multiple traumas. Although prolonged ECMO may be necessary, excellent outcomes are frequently associated. In this study, we report long-term support with venovenous-ECMO applied in a child with severe blunt trauma in Korea. This 10-year-old and 30 kg male with severe blunt thoracic trauma after a car accident developed severe ARDS a few days later, and ECMO was administered for 33 days. Because of pulmonary hemorrhage during ECMO support, heparin was stopped for 3 days and then restarted. He was weaned from ECMO successfully and has been able to run without difficulty for the 2 years since discharge.

Extracorporeal life support is safe in trauma patients

INTRODUCTION

The role of extracorporeal life support (ECLS) in the critically ill trauma patient is poorly defined, possibly leading to the underutilization of this lifesaving therapy in this population. This study examined survival rates and risk factors for death in trauma patients who received ECLS.

METHODS

Data from the National Trauma Data Bank was retrospectively reviewed to identify trauma patients who received ECLS from January 2012 to December 2014. Clinical outcomes and risk factors for death were examined in these patients.

RESULTS

Eighty patients were identified and included in the final analysis. Overall survival to hospital discharge was 64%. Survivors and non-survivors were similar in regard to age, gender, weight, and injury mechanism. Non-survivors had greater median injury severity scores (ISS) (29 non-survivors vs. 24 survivors, p=0.018) and had a shorter median total hospital length of stay (8days non-survivors vs. 32days survivors, p<0.001). Analysis of specific anatomic locations of traumatic injury, including serious head/neck, thoracic, and abdominal injuries, revealed no impact on patient survival. Multivariable logistic regression analysis identified increasing age and ISS as significant risk factors for mortality; whereas treatment at facilities that performed multiple ECLS runs over the study period was associated with improved survival.

CONCLUSIONS

Extracorporeal life support appears to be an effective treatment option in trauma patients with severe cardiopulmonary failure. Survival in trauma patients receiving ECLS is similar to that observed in the general ECLS population and this may represent an underutilized therapy in this population.

Outcome measures of extracorporeal life support (ECLS) in trauma patients versus patients without trauma: a 7-year single-center retrospective cohort study

This single-center retrospective study included a total of 99 extracorporeal life support (ECLS) cannulated patients assigned to a traumatic extracorporeal life-support cohort (TECLS) or a non-traumatic extracorporeal life-support cohort (NTECLS). Forty-nine TECLS patients and 50 NTECLS patients were compared. The TECLS patients were significantly younger [49.9 years 16.6-86.2 vs. 57.1 (21.4-78.6); p = 0.007] and had lower body mass indices (BMIs) [27.7 kg/m² (20-37) vs. 32.5 (19-88.5); p = 0.001] than the NTECLS patients. The intensive care unit (ICU) survival rate [n = 34 (69.4%) vs. n = 13 (26%); p ≤ 0.001] and the hospital survival rate [n = 32 (65.3%) vs. n = 13 (26%); p ≤ 0.001] were significantly higher for the TECLS cohort than for the NTECLS cohort. The lengths of stay (LOSs) in the ICU [24 days (4.8-71.1) vs. 11.3 (0-88.6); p = 0.001] and in the hospital [46.6 days (2.9-197.6) vs. 21 (0.1-213.8); p = 0.001] were significantly longer for the TECLS patients than for the NTECLS patients.

Extracorporeal membrane oxygenation improves coagulopathy in an experimental traumatic hemorrhagic model

Purpose

Hemorrhage is the most common cause of preventable death after trauma. Coagulopathy plays a central role in uncontrolled bleeding and is caused by multiple factors. Extracorporeal Membrane Oxygenation (ECMO) is an established treatment for patients with respiratory failure and has in recent years also been used in severely injured trauma patients with cardiopulmonary failure and coexisting bleeding shock. The aim of this study was to evaluate the effect of ECMO on hypothermia, acidosis, and coagulopathy in a traumatic hemorrhagic rabbit model.

Methods

After anesthesia and tracheostomy, ten New Zealand White rabbits sustained laparotomy, bilateral femur fractures and were hemorrhaged 45% of their estimated blood volume. After 90 min of hemorrhagic shock they were resuscitated with a standard transfusion protocol together with venoarterial ECMO (n = 5) or with a standard transfusion protocol only (n = 5) for 60 min. No systemic heparin was administered.

Results

ECMO during 60 min of resuscitation significantly increased heart rate (p = 0.01), mean arterial pressure (p = 0.01), body temperature (p = 0.01) and improved the metabolic acidosis, pH (p = 0.01), and lactate (p = 0.01). ECMO also improved the coagulation capacity measured in vitro by Rotational Thromboelastometry with a significant decrease in clot formation time (p < 0.01). This finding was confirmed in vivo with a significant reduction in the animals’ ear bleeding time (p < 0.01) and cuticle bleeding time (p < 0.01); 5/5 animals survived in the ECMO group and 3/5 animals survived in the control group.

Conclusions

Heparin-free ECMO stabilizes circulation, improves coagulation, and may impact short-time survival, during the first 60 min, in an experimental traumatic model with severe hemorrhagic shock.

Trauma and acute lung injury

Acute lung injury is a serious complication of major trauma occurring as a direct consequence of trauma to the lung or, more commonly, arising indirectly as a consequence of trauma elsewhere to the body. A spectrum of severity exists with acute respiratory distress syndrome (ARDS) defined as the most severe form of injury. The frequency of ARDS with severe trauma is unclear but is believed to occur in approximately 15- 25% of cases, although this is confused by the effects of multiple transfusions and associated injuries including burns and head injury. ARDS from all causes is estimated to occur with a frequency of two to 10 cases per 100 000 population. It causes a huge social and financial impact, with many survivors requiring a prolonged critical care stay and a significant number having a persisting poor quality of life a year after the injury. The mortality is, however, decreasing and stands at approximately 40%. A number of approaches are now recognized that can improve oxygenation and large trials have identified best critical care practice, leading to a reduction in ventilator-induced injury, with associated improvements in outcome.

Is it possible to predict outcome in cardiac ECMO? Analysis of preoperative risk factors

Background. Serious heart failure may be treated with extracorporeal membrane oxygenation (ECMO) when other treatment fails. The aim of the present study was to analyse preoperative risk factors of early mortality in patients treated with veno-arterial (VA)-ECMO. Methods. We studied a total of 18 possible risk factors in 80 patients with severe cardiac insufficiency treated with VA-ECMO. All consecutive cases treated at our institution between Sept.1990 and May 2006 were included. Univariate analysis and multiple logistic regression analysis were performed on 16 risk factors. The endpoint was early mortality (any death within 30 days of ECMO treatment). Results. Thirty patients (37.5%) died within 30 days. Age, gender, cause of cardiac failure, pre-ECMO treatment (ventilator, NO, IABP) did not significantly influence early mortality. A higher SvO2 was associated with survival and remained significant in the multivariate analysis. Conclusion. Treatment with VA-ECMO in patients with severe cardiac failure may save lives. It is, however, difficult to predict outcome. In this study, only SvO2 values prior to ECMO were positively associated with survival. Perfusion (2007) 22, 225—229.

Early Percutaneous Heparin-Free Veno-Venous Extra Corporeal Life Support (ECLS) is a Safe and Effective Means of Salvaging Hypoxemic Patients with Complicated Chest Trauma

BACKGROUND

The objective of this study was to assess the feasibility and safety of heparin-free veno-venous extracorporeal life support (VV ECLS) as a means of salvaging polytrauma patients with life-threatening hypoxemia.

METHODS

This is a retrospective observational study on 7 consecutive trauma patients who underwent VV ECLS for severe chest trauma unresponsive to conventional measures.

RESULTS

The median time to ECLS was within 10 hrs (IQR 2-53) of mechanical ventilation. Surgical interventions were performed before and during ECLS based on management priorities consistent with advanced trauma life support guidelines. No heparin was used for at least 4 days in this group with activated coagulation time (ACT) approximating 170 seconds by the 3(rd) and 4(th) day. There were no thromboembolic complications. Four patients were successfully discharged and three of these survivors had concomitant traumatic brain injury (TBI) without neurologic sequel.

CONCLUSIONS

Early VV ECLS can be used for salvage of patients with traumatic lung injury. Acute trauma care can be continued as needed under heparin-free ECLS without the fear of thromboembolic complications.

KEY WORDS

Adult respiratory distress syndrome; Extracorporeal life support; Multiple trauma; Thoracic injury; Traumatic brain injury.

Extracorporeal life support in polytraumatized patients

Major trauma is a leading cause of death, particularly amongst young patients. Conventional therapies for post-traumatic cardiovascular shock and acute pulmonary failure may sometimes be insufficient and even dangerous. New approaches to trauma care and novel salvage techniques are necessary to improve outcomes. Extracorporeal life support (ECLS) has proven to be effective in acute cardiopulmonary failure from different etiologies, particularly when conventional therapies fail. Since 2008 we have used ECLS as a rescue therapy in severe poly-trauma patients with refractory clinical setting (cardiogenic shock, cardiac arrest, and/or pulmonary failure). The rationale for using ECLS in trauma patients is to support cardiopulmonary function, providing adequate systemic perfusion and, therefore, avoiding consequent multi-organ failure and permitting organ recovery. From our data ECLS, utilizing heparin-coated support to avoid systemic anticoagulation, is a valuable option to support severely injured patients when conventional therapies are insufficient. It is safe, feasible, and effective in providing hemodynamic support and blood-gas exchange. Moreover, we have identified several pre-ECLS patient characteristics useful in predicting ECLS treatment appropriateness in severe poly-traumatized patients. These might be helpful in deciding whether the ECLS should be initiated in patients who are severely complex and compromised. Future improvements in materials and techniques are expected to make ECLS even easier and safer to manage, leading to a further extension of its use in severely injured patients.

Veno-arterial extracorporeal membrane oxygenation support for severe cardiac failure in a pediatric patient with intracranial hemorrhage after spontaneous aneurysmatic rupture

Introduction:

Extracorporeal life support in adult patients with extended intracranial hemorrhage is controversial. In pediatric patients, it has traditionally been considered a contraindication as systemic anticoagulation may worsen the hemorrhage and neurological outcome.

Case history:

We present a nine-year-old female patient who was admitted with extended intracranial hemorrhage after spontaneous rupture of an aneurysm. On day four after the emergency craniotomy, she required veno-arterial extracorporeal membrane oxygenation for septic shock. Using an adapted anticoagulation protocol aimed at lower activated partial thromboplastin time target values, we did not observe any new bleeding or clotting complications during systemic anticoagulation and the patient had good neurological recovery.

Conclusion:

Extracorporeal life support with low dose systemic anticoagulation can be considered as a treatment option in pediatric patients after craniotomy for intracranial aneurysmatic hemorrhage.

Extracorporeal membrane oxygenation for cardiac arrest during moyamoya cerebral revascularization surgery: case report

The authors describe the case of a 51-year-old man with bilateral moyamoya disease and prior strokes who developed an asystolic cardiac arrest while undergoing revascularization surgery under mild hypothermia. The patient was successfully treated with venoarterial (VA) extracorporeal membrane oxygenation (ECMO) after manual cardiopulmonary resuscitation (CPR) was unsuccessful for 45 minutes. ECMO is a cardiopulmonary support system that is indicated for respiratory failure in pediatric and adult patients. It is increasingly being used as an extension to mechanical CPR for patients who have suffered cardiac arrest if the underlying cause of cardiac arrest is thought to be reversible. Identifying which patients should be placed on emergency ECMO after cardiac arrest is controversial given its high morbidity and mortality. ECMO in neurosurgical settings has associated risks of intracranial hemorrhage and neurological compromise, while resource utilization is paramount given the high costs of this treatment. This paper is significant because it describes the use of ECMO in an unindicated setting. Limited data are available for ECMO usage after cardiac arrest with baseline cerebral ischemia. Furthermore, this paper raises important considerations for extracorporeal CPR use in a patient who had recently undergone craniotomy. The patient in this report remained on ECMO for 48 hours, after which he was successfully weaned. He developed a pericardial effusion and compartment syndrome from the ECMO but made a complete neurological recovery. Use of ECMO emergently in an appropriately chosen neurosurgical patient is safe, even in the setting of baseline cerebral ischemia and recent craniotomy.

Extracorporeal membranous oxygenation (ECMO) in polytrauma: what the radiologist needs to know

The purpose of this article is to review the spectrum of severe traumatic injuries treatable with ECMO and their imaging features, considerations for cannula placement, and complications that may arise in polytraumatized patients on extracorporeal life support. Recent major advances in miniaturization and biocompatibility of ECMO devices have dramatically increased their safety profile and expanded the application of ECMO to patients with severe polytrauma.

The use of double lumen cannula for veno-venous ECMO in trauma patients with ARDS

Background

The use of a double lumen cannula for veno-venous extracorporeal membrane oxygenation (v.v. ECMO) offers several advantages such as cannulation with only one cannula, patient comfort and the earlier mobilization and physiotherapy. The cannulation should be performed under visual wire and cannula placement into the right atrium, which is associated with risks of malposition and right ventricular perforation. The aim of this patient series is to describe the use of double lumen cannula in trauma patients with posttraumatic ARDS.

Material and methods

Criteria for the v.v ECMO treatment were defined as hypoxaemia (pO2/FiO2 < 200 mmHg, FiO2 0.8-1,0); tidal volume >4-6 ml/kg ideal body weight; mean inspiratory pressure (Pinsp) >32-34 mmHg; respiratory acidosis pH <7.25; and arterial saturation (SaO2) <90%. The analysis included the Injury Severity Score (ISS), the types of injury, time of treatment, complications and outcomes.

Results

A total of 24 patients with major trauma were treated for posttraumatic ARDS with v.v. ECMO. The double lumen cannula (Avalon®, Fa. Maquet, Rastatt, Germany) was used in six male patients. The mean ISS was 31 (20–48). The ECMO therapy was started in an average on the third day after trauma. The mean ECMO run time was 7 days ± 5 (6–18), and the hospital stay was in mean of 60 days ± 34 (21–105).

Conclusion

The use of double lumen cannula for v.v ECMO therapy in trauma patients is a feasible treatment option. No higher risk of bleeding could be found in this case series. A PTT-controlled heparinization is recommended using double lumen cannula. Therefore the use of this cannula type in trauma patients with high risk of bleeding is to discuss controversially.

Non-heparinized ECMO serves a rescue method in a multitrauma patient combining pulmonary contusion and nonoperative internal bleeding: a case report and literature review

Pulmonary contusion and acute respiratory distress syndrome (ARDS) is a common manifestation in polytraumatic patients. Although mechanical ventilation is still the first choice of treatment, a group of patients are still unable to maintain their oxygenation. The role of extracorporeal membrane oxygenation (ECMO) has been more clarified when the lung is extensively damaged and when conventional modality failed. ECMO provides the lung an opportunity to rest by permitting reduced ventilator settings and limiting further barotraumas. However, ECMO is still considered contraindicated in polytramatic patients combining pulmonary contusion and other organ hemorrhage because of systemic anticoagulation during the treatment. We herein report a patient who successfully survive a multitrauma combining pulmonary contusion and grade IV liver laceration using non-heparinized venovenous extracorporeal membrane oxygenation (vv-ECMO). The associated literature were reviewed.

ECMO support for right main bronchial disruption in multiple trauma patient with brain injury--a case report and literature review

Extracorporeal membrane oxygenation (ECMO) may offer life-saving treatment in severe pulmonary contusion or acute respiratory distress syndrome when conventional treatments have failed. However, because of the bleeding risk of systemic anticoagulation, ECMO should be performed only as a last resort in multiple trauma victims. Here, we report ECMO as a bridge for right main bronchus reconstruction and recovery of traumatic wet lung in a 31-year-old male multi-trauma patient with right main bronchial disruption, bilateral pulmonary contusion, cerebral contusion and long bone fracture. The patient was discharged without any obvious complication. ECMO support in a traumatic brain injured patient with severe hypoxemia caused by lung contusion and/or tracheal bronchus disruption is not an absolute contraindication.

Salvage techniques in traumatic cardiac arrest: thoracotomy, extracorporeal life support, and therapeutic hypothermia

PURPOSE OF REVIEW

Survival from traumatic cardiac arrest is associated with a very high mortality despite aggressive resuscitation including an Emergency Department thoracotomy (EDT). Novel salvage techniques are needed to improve these outcomes.

RECENT FINDINGS

More aggressive out-of-hospital interventions, such as chest decompression or thoracotomy by emergency physicians or anesthesiologists, seem feasible and show some promise for improving outcomes. For trauma patients who suffer severe respiratory failure or refractory cardiac arrest, there seems to be an increasing role for the use of extracorporeal life support (ECLS), utilizing heparin-bonded systems to avoid systemic anticoagulation. The development of exposure hypothermia is associated with poor outcomes in trauma patients, but preclinical studies have consistently demonstrated that mild, therapeutic hypothermia (34 °C) improves survival from severe hemorrhagic shock. Sufficient data exist to justify a clinical trial. For patients who suffer a cardiac arrest refractory to EDT, induction of emergency preservation and resuscitation by rapid cooling to a tympanic membrane temperature of 10 °C may preserve vital organs long enough to allow surgical hemostasis, followed by resuscitation with cardiopulmonary bypass.

SUMMARY

Salvage techniques, such as earlier thoracotomy, ECLS, and hypothermia, may allow survival from otherwise lethal injuries.