Extracorporeal Membrane Oxygenation May Improve Outcomes After Resuscitative Thoracotomy: A National Trauma Data Bank Analysis

Abstract

Background Albeit low survival rates, resuscitative thoracotomy (RT) is considered standard for selected trauma patients. Because it has potential for rapid cardiopulmonary rescue, extracorporeal membrane oxygenation (ECMO) may augment RT. The aim of this study was to identify the impact of ECMO on trauma patients that recently underwent RT after injury. Study Design All patients who underwent RT were identified from the National Trauma Data Bank (2007-2017). Patients were excluded if they died within 60 minutes, underwent delayed ECMO, and/or had missing data. Delayed ECMO group was defined as those patients undergoing ECMO after 1 hour following RT. Results Out of 8 694 272 injured patients, 10 106 (.1%) underwent RT. Median age was 31 years [23-45], 86% male. Penetrating injury was the dominant mechanism (62%). Of these, .6% (23) underwent immediate ECMO. Extracorporeal membrane oxygenation patients were significantly younger (23[17-33] vs. 31[23-46], p .003) and had significantly higher chest abbreviated injury scale scores (5[4-5] vs. 3[3-4], P < .001). Extracorporeal membrane oxygenation patients achieved significantly higher rate of return of spontaneous circulation (96% vs. 70%, p .007) and had nonsignificant trend of improved mortality (52% vs. 63%, p .260). Conclusion Immediate ECMO may be a useful therapeutic modality after RT. It achieves higher ROSC rates with opportunity for improved survival. Future prospective study is warranted.

Characterization of cerebral blood flow during open cardiac massage in swine: Effect of volume status

“…Open cardiac massage (OCM) and aortic cross clamping (x-clamping) is performed in trauma patients presenting in cardiac arrest via resuscitative thoracotomy (RT) as a lastditch heroic maneuver. (Burlew et al, 2012;Morrison and Rasmussen, 2012;Morrison et al, 2013;Inaba et al, 2015;Carroll et al, 2020;DuBose et al, 2020;Madurska et al, 2021;Owattanapanich et al, 2021). The goal of OCM is to generate a coronary perfusion pressure sufficient to perfuse the myocardium and promote the return of a spontaneous circulation (ROSC).…”

“…The goal of OCM is to generate a coronary perfusion pressure sufficient to perfuse the myocardium and promote the return of a spontaneous circulation (ROSC). (Burlew et al, 2012;Morrison and Rasmussen, 2012;Morrison et al, 2013;Inaba et al, 2015;Carroll et al, 2020;DuBose et al, 2020;Madurska et al, 2021;Owattanapanich et al, 2021). X-clamping increases afterload and helps focus the limited cardiac output toward the heart and brain.…”

Whole Blood Selective Aortic Arch Perfusion for Exsanguination Cardiac Arrest: Assessing Myocardial Tolerance to the Duration of Cardiac Arrest

“…In a hospital setting this requires equipment availability, but can be applied quickly and with procedural times likely similar to thoracotomy and vascular access. With the data presented herein, these patients meeting resuscitative thoracotomy guidelines would also quality for SAAP, and may have better survival (8,9,21).…”

“…And would this feasible in a trauma bay for applications shortly after arrest? While more data are needed to assess prehospital implementation, this would be technically easier than prehospital ECMO, which is being investigated or used in some locations (8), but more technically challenging than REBOA. In a hospital setting this requires equipment availability, but can be applied quickly and with procedural times likely similar to thoracotomy and vascular access.…”

“…The goal of these procedures is to focus perfusion on the heart and brain until global systemic circulation can be restored. Despite these extreme measures, outcomes after ECA remain poor and do not appear to be improving (6)(7)(8)(9). New resuscitative techniques are needed for the management of this complex medical and anatomic problem.…”