Magnus Larsson
This episode is all about ECMO in trauma - not the usual ARDS, TRALI VV-ECMO - we’re talking about VA ECMO for the acutely dying trauma patient. Zack interviews Pål Ager-Wick from Tromso Norway, and Magnus Larsson from the Karolinska Institute in Stockholm. We talk about everything from how ECMO helps the hemorrhaging trauma patient to the futuristic “Emergency Preservation and Resuscitation” concept being done in Baltimore now.
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ECMO in trauma
This episode is all about ECMO in trauma – not the usual ARDS, TRALI VV-ECMO – we’re talking about VA ECMO for the acutely dying trauma patient. Zack interviews Pål Ager-Wick from Tromso Norway, and Magnus Larsson from the Karolinska Institute in Stockholm. We talk about everything from how ECMO helps the hemorrhaging trauma patient to the futuristic “Emergency Preservation and Resuscitation” concept being done in Baltimore now.
Bullet Points:
- VV ECMO –
- Marginal data suggests ECMO beneficial in ARDS (CESAR, ANZECMO trials)
- ARDS and TRALI in trauma is a reasonable extension of this
- Damage Control Surgery –
- focus on coagulation
- stop major bleeders and then take to ICU
- lethal triad of coagulation includes hypothermia, dilution of coagulation factors and acidosis
- Coagulation of trauma: ECMO can improve all three components of lethal triad
- Heparin has been successfully withheld in bleeding trauma patients
- ECMO in Severe Chest Trauma – 10 patients, 8 ruptured cardiac chambers1
- Blunt cardiac arrest – a case report2
- Bleeding less than 15% mortality after 1995, Intracranial hemorrhage patients can survive. In fact none of the ICH patients on ECMO who died died of brain bleeding (60-93% survived). Survival was 42-63% for VA ECMO. Lower ACT (<180 sec)3
- ELSO – VA ECMO in trauma – 45% survival4
- ECMO reduces venous pressure which may be beneficial in hemorrhaging patients5
- Tisherman – Suspended Animation: Emergency Preservation and Resuscitation678
References
1.
Huh U, Song S, Chung S, et al. Is Extracorporeal Cardiopulmonary Resuscitation Practical in Severe Chest Trauma? : A Systematic Review in Single Center of Developing Country. J Trauma Acute Care Surg. August 2017. [PubMed]
2.
Kudo S, Tanaka K, Okada K, Takemura T. Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture: A case report. Am J Emerg Med. August 2017. [PubMed]
3.
Bedeir K, Seethala R, Kelly E. Extracorporeal life support in trauma: Worth the risks? A systematic review of published series. J Trauma Acute Care Surg. 2017;82(2):400-406. [PubMed]
4.
ELSO Registry. Extracoporeal Life Support Organization. http://www.elso.org/Registry/Statistics/InternationalSummary.aspx.
5.
Larsson M, Talving P, Palmér K, Frenckner B, Riddez L, Broomé M. Experimental extracorporeal membrane oxygenation reduces central venous pressure: an adjunct to control of venous hemorrhage? Perfusion. 2010;25(4):217-223. [PubMed]
6.
Tisherman S, Safar P, Radovsky A, Peitzman A, Sterz F, Kuboyama K. Therapeutic deep hypothermic circulatory arrest in dogs: a resuscitation modality for hemorrhagic shock with “irreparable” injury. J Trauma. 1990;30(7):836-847. [PubMed]
7.
Tisherman S. Salvage techniques in traumatic cardiac arrest: thoracotomy, extracorporeal life support, and therapeutic hypothermia. Curr Opin Crit Care. 2013;19(6):594-598. [PubMed]
8.
Kutcher M, Forsythe R, Tisherman S. Emergency preservation and resuscitation for cardiac arrest from trauma. Int J Surg. 2016;33(Pt B):209-212. [PubMed]
heparin. if i remember correctly, Chris Nickson said that our Australian friends use heparinized lines, but do not heparinize their patients. and they do very well. (think i heard that right…).
Pal says that the Swedes use “factor 11”? which thins the blood, but doesn’t increase bleeding?
just researched it… thats exciting as well. the targets of the new potential meds are factor XII or XI. anticoagulation with little or no affect on hemostasis.
ecmo for trauma… how truly exciting. thanks Pal and Zack.
Hello, Revently transport a early 50s year-old male trauma patient involved in a single vehicle rollover from a regional hospital to the trauma center. He had extensive bilateral pulmonary contusions who became progressively difficult to ventilate and oxygenate. Had multiple cardiac arrests and unfortunately died. I wonder if vv-ECMO could have been beneficial.