ECMO in trauma care: What you need to know

Abstract

Over the past 10 years, extracorporeal membrane oxygenation (ECMO) use in trauma patients has increased significantly. This includes adult and pediatric trauma patients and even combat casualties. Most ECMO applications are in a venovenous (VV ECMO) configuration for acute hypoxemic respiratory failure or anatomic injuries that require pneumonectomy or extreme lung rest in a patient with insufficient respiratory reserve. In this narrative review, we summarize the most common indications for VV ECMO and other forms of ECMO support used in critically injured patients, underscore the importance of early ECMO consultation or regional referral, review the technical aspects of ECMO cannulation and management, and examine the expected outcomes for these patients. In addition, we evaluate the data where it exists to try to debunk some common myths surrounding ECMO management.

Figure 1.. ECMO in Trauma Care.

Indications include the most common examples where venovenous extracorporeal membrane oxygenation (VV ECMO) should be considered in critically injured patients, but this does not represent an exhaustive list of potential indications for either VV ECMO or venoarterial (VA) ECMO in trauma. ECMO consultation should be initiated early in patients with potential indications. *Heparin bolus and infusion are preferred but not required in patients with a high risk of bleeding or in patients at risk of significant neurologic consequences from a bleeding complication (e.g., traumatic brain injury, spinal epidural hematoma).

Figure 2.. Trans-thoracic Echocardiographic View of ECMO Cannula.

Double lumen VV cannulation via right IJ vein. The catheter is shown coursing from the SVC across RA into the IVC. Note hepatic vein at top left of image; the distal/ drainage lumen should rest in the IVC rather than the hepatic vein. The proximal/ reinfusion lumen can be seen as an irregularity in the catheter wall. Color flow doppler also demonstrates appropriate positioning of the proximal/reinfusion lumen, with blood flow directed into the right atrium.

Figure 3.. Clinical Case Examples.

Of the 30 critically injured patients managed in our trauma center on ECMO from 2015 to present, 23 have survived to discharge (77%). ECMO patients included both blunt (n=18, 60%) and penetrating (n=12, 40%) mechanisms with a median ISS of 25. A-C, 48 year old male with a history of a heart transplant fell from a 2^nd story window. He was hypoxemic on initial evaluation and a chest tube was placed for significant subcutaneous emphysema and a presumed pneumothorax. His oxygenation did not improve; so ECMO cannulation was initiated. Mechanical stabilization of his ribs was considered but then not performed based on estimated risks in this patient outweighing potential benefits. He recovered and was discharged to home. D-F, 27 year old male helmeted motorcyclist involved in a motorcycle crash resulting in multiple rib fractures, a sternal fracture, bilateral hemo-pneumothoraces and pulmonary contusions, bilateral T4 pedicle fractures without spinal cord injury, a small subdural hematoma, and a femur fracture. After early femoral nail placement, he developed severe ARDS prompting transfer to our ECMO center. He was promptly cannulated and remained on ECMO for 40 days. He subsequently recovered and was discharged to an acute rehabilitation facility in good condition. G-I, 21 year old male who suffered a gunshot wound to the lower abdomen with injuries to the aorta and inferior vena cava as well as multiple bowel injuries. He developed a post-operative pulmonary embolism managed with catheter embolectomy; however, his oxygenation worsened post-procedure due to possible re-perfusion injury. VV ECMO was initiated (large arrows) as well as hemodialysis for acute renal failure (small arrow). He subsequently recovered, was decannulated, and transferred to an acute rehabilitation facility in good condition.

Figure 4.. ECMO Cannula Securement and Assessment.

Cannulas should periodically be checked for intact suture fixation with no evidence of migration.