Associate Professor Samuel Galvagno: ECMO. From CICM ASM PROGRAM 2019

1. R ADAMS COWLEY SHOCK TRAUMA CENTER
The Use of Extracorporeal
Membrane Oxygenation (ECMO) in
Trauma Patients
Sam Galvagno, DO, PhD, FCCM
Col, USAF, MC, SFS
Associate Professor
Medical Director, Lung Rescue Unit (LRU)
University of Maryland School of Medicine
R Adams Cowley Shock Trauma Center
Baltimore, MD, USA

2. R ADAMS COWLEY SHOCK TRAUMA CENTER
Disclosures
• United States Air
Force Reserve
• UpToDate®
Author
• Department of
Defense Funding

3. R ADAMS COWLEY SHOCK TRAUMA CENTER
Objectives
• Describe the physiological rationale for
application of ECMO
• Assess the available literature
• List indications for VV and VA ECMO
• Through case studies:
• Critically appraise the use of ECMO for
distinct cohorts of trauma patients

4. R ADAMS COWLEY SHOCK TRAUMA CENTER
R Adams
Cowley
Shock
Trauma
Center

5. R ADAMS COWLEY SHOCK TRAUMA CENTER

6. One Big Shunt

7. Configurations
MOST COMMON

8. VA ECMO

9. R ADAMS COWLEY SHOCK TRAUMA CENTER
VV ECMO Goals
Hypoxemia (PaO2 40-60, SaO2 70-90 %)
occurs with VV-ECMO BUT is adequate to
maintain normal oxygen delivery
Goal DO2/VO2 > 3
SaO2 > 80%
Bartlett RH. The ELSO Red Book (5th Ed), 2017.

10. R ADAMS COWLEY SHOCK TRAUMA CENTER
CardioHelp ® RotaFlow ®
$30,000
($ 43,390 AUD)
Circuits~$2,000
($ 2892 AUD)
$130,000
($ 188,000 AUD)
Circuits~$13,000
($ 18,800 AUD)

11. ECMO Growth
ELSO Registry, Jan 2019, www.elso.org
CESAR trial/H1N1 epidemic

12. ECMO Growth
ELSO Registry, Jan 2019, www.elso.org
CESAR trial/H1N1 epidemic

13. R ADAMS COWLEY SHOCK TRAUMA CENTER
Indications and outcomes of extracorporeal life support in trauma patients
Swol J, Brodie D, Napolitano L, et al., et al.
Wurzberg, Germany
Columbia, NY, USA
Michigan, USA J Trauma Acute Care Surg. 2018; 845.

14. Indications and outcomes of extracorporeal life support in trauma patients
Swol J, Brodie D, Napolitano L, et al., et al.
Wurzberg, Germany
Columbia, NY, USA
Michigan, USA J Trauma Acute Care Surg. 2018; 845.

15. Indications and outcomes of extracorporeal life support in trauma patients
Swol J, Brodie D, Napolitano L, et al., et al.
Wurzberg, Germany
Columbia, NY, USA
Michigan, USA J Trauma Acute Care Surg. 2018; 845.
Trauma Survival vs. other ECMO Indications

16. 100
90
80
70
60
50
40
30
20
10
Year
Survival(%)
Summary of Other VV ECMO Studies in Trauma
1999-2018
All other trauma indications Trauma-related ARDS

17. R ADAMS COWLEY SHOCK TRAUMA CENTER
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
Menaker J, Tesoriero R, Tabatabai A., et al.
Baltimore, MD World J Surg. 2018; 42..
• 18 patients over 2 years
• Mean ISS: 27
• Mean lactate prior to cannulation: 7.3 mmol/L
• Mean P/F ratio pre-ECMO: 61
• 14 (78%) survived to hospital discharge

18. R ADAMS COWLEY SHOCK TRAUMA CENTER
STC Criteria
• Post traumatic pneumonectomy
OR
• PaO2 < 100 mmHg with Fi02 ≥ 80%,
and Pplat ≥ 30 cm H20 or P1 ≥ 30 cm
H20 (APRV)
• Hypercapnia (CO2>60) with pH
<7.25, or inability to adequately
ventilate with Pplat ≤ 30 or P1 ≥ 30
(APRV)
• On ventilator ≤ 10 days
• < 65 years of age
• Reversable form of ARDS
• Bedside physician clinical discretion
• ≥ 65 years of age
• Pre-admission home O2 use for severe
lung disease
• Terminal disease with low 1 year survival
rates
• Jehovah’s Witness/unwilling to accept
blood products
• Underlying cirrhosis (Child class C or
MELD ≥ 30 )
• Abdominal compartment syndrome
(treat first then re-eval need for ECMO)
• Uncontrolled hemorrhage
• Severe traumatic brain injury (case by
case discussion)
• Bedside physician clinical discretion
The use of VA ECMO following injury is discouraged unless it is a direct cardiac injury
(case by case discussion)
Inclusion Exclusion

19. R ADAMS COWLEY SHOCK TRAUMA CENTER
Protocolized Management
• Ventilator Management
• PCV: 20 / PEEP 10 / rate 10
• Proned: 25 / PEEP 15 / rate 10
• FiO2 40%  30%
• Hematological Goals
• Hgb > 8 mg/dL  7 once stable
• Plts > 40,000
• Heparin infusion for aPTT 45-55 s

20. R ADAMS COWLEY SHOCK TRAUMA CENTER
Protocolized Management
• Proning
• First session 8 hrs.  16 hrs. / day
• ECMO Settings
• Blood flow for SpO2 > 88% (SaO2 > 80%)
• Sweep gas flow for PaCO2 35-45
• PaCO2 35-40 for right ventricular dysfunction
• Empiric inotropic epinephrine and epoprostenol
• Recirculation x 12-24 hrs. before
decannulation

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Post Cannulation
• Duplex of cannula sites and IVC 24 hours post
decannulation
• 85% have CaDVTs
• Positive results are treated with full systemic
anticoagulation
• All positive duplex results repeated at 2 weeks
• Positive duplex results treated x 3 months
• (full systemic anticoagulation)
• If no residual clot, systemic anticoagulation
stopped
Menaker J. ASAIO J. 2017.

23. R ADAMS COWLEY SHOCK TRAUMA CENTER
CASES

24. Case # 1
• 18-year-old male, dirt bike crash
– Intubated pre-hospital
– GCS 3T on arrival
– Pupils 3 mm non reactive
– Lower leg deformity
– BP 136/85, HR 110
– WBC 38, B.E. -1.3

26. MRSA
Pneumonia
Intracranial monitor placed
• Initial ICP is 9
• Best GCS 1-4-1
HD 7 : increased ventilator needs
• APRV
• Cisatracurium infusion
• Proning
• Barotrauma requiring chest tube
placement
MRI: grade 3 DAI

28. R ADAMS COWLEY SHOCK TRAUMA CENTER

29. R ADAMS COWLEY SHOCK TRAUMA CENTER
Case # 1
• Do you offer the family ECMO?
– Yes?
– No?
– Why or why not?
– How would you cannulate?

30. R ADAMS COWLEY SHOCK TRAUMA CENTER
Case #1
• Bi-femoral cannulation
• Left femoral: 25 Fr drainage/outflow
– Right femoral 23 Fr return/inflow
– 2500 units heparin given prior to cannulation
– Heparin infusion started on ECMO day 5
• aPTT goal 45-55
– Serial head CTs with no evidence of worsening hemorrhage
– Decannulated 2/27/19 (41 days)
– Discharge from hospital 2 months later
• GCS 11T

31. R ADAMS COWLEY SHOCK TRAUMA CENTER
Case # 2
• 26-year-old male unbelted, MVC, ejected, “bounced off
the guard rail”
• Deep laceration to anterior neck
• Diverted to local hospital for airway
– Portex trach placed through wound
• Arrived to STC
– BP – 80/P  145/75
– HR – 107
– SpO2 – “not measuring”
• 1st SpO2 was 87%

32. R ADAMS COWLEY SHOCK TRAUMA CENTER
Case # 2
• Uncooperative and agitated on arrival
• “Large wound to the anterior part of the neck
with exposed soft tissue and surgical airway in
place”
• “20 cm sized complex laceration to the right
lateral chest extending posteriorly
Complex laceration to the perineal region
around the perianal region deep into the
muscular layer ”

33. R ADAMS COWLEY SHOCK TRAUMA CENTER
Case # 2
• Traumatic brain injury: small parafalcine subdural hematoma
• Tracheal separation (2/3 of trachea disrupted)
• C2-C3 distraction injury and prevertebral hematoma
• Bilateral pneumothoraces
• Right greater than left lung contusions; right lung laceration
• Right midclavicular fracture, displaced
• Right and left scapular fractures
• Right rib fractures (2-5)
• Left rib fractures (2-4)
• Right hemothorax
• Grade IV splenic laceration with pseudoaneurysms
• T5-T6 endplate fracture
• Bilateral vertebral artery injuries (grade 1)
ISS = 66

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36. R ADAMS COWLEY SHOCK TRAUMA CENTER

37. R ADAMS COWLEY SHOCK TRAUMA CENTER
Case # 2
• PCV 36 / 10 / FiO2 100%
• ABG: 7.08/70/90/91.7/-10.8
• Do you cannulate?
• How?

39. R ADAMS COWLEY SHOCK TRAUMA CENTER
Case # 2
• OPERATION:
• 1. Splenectomy.
• 2. Colostomy.
• 3. Gastrojejunostomy tube.
• 4. Neck exploration with debridement.
• 5. Primary tracheal repair.
• 6. Local muscle advancement.
• 7. Flexible bronchoscopy.
• 8. EGD
• Massively transfused

41. R ADAMS COWLEY SHOCK TRAUMA CENTER
Case # 2
• No heparin used due to brain injury
• 6 days on ECMO
• 38 day hospital stay
• Discharged to rehab
– Neurologically intact
– Tracheostomy removed

42. R ADAMS COWLEY SHOCK TRAUMA CENTER
Case # 3
• Young male, found down,
unresponsive, GCS 3T
• Intubated prior to arrival.
• Initial VS
– SBP 160/p  136/87
– HR 125
– EtCO2 - 25
• Initial labs
– 6.91/72/80/14/-
18.4/88%
– Lactate 6.7
– Lyse 30 – 26.9

43. R ADAMS COWLEY SHOCK TRAUMA CENTER
Case 3
• Exploratory laparotomy
• Splenectomy
• Right nephrectomy
• Liver packing
• Temporary abdominal closure
• Left anterolateral thoracotomy
• Left lower lobe wedge resection
• Combat gauze
• Lap pads placed
• Temporary chest closure
MASSIVE TRANSFUSION +++

44. R ADAMS COWLEY SHOCK TRAUMA CENTER
• 7.18/64/87/23/93%
• Platelets 27
• Lactate 4.8
• TEG angle 49 / MA 46
• FiO2 100%
• PEEP 20
• Epi/norepi/vaso
• Cisatracurium
• Inhaled epoprostenol
• Ongoing transfusion
Cannulate for VV ECMO?

45. 7.26/47/138/20/97.3
PCV 25/15/40%

46. R ADAMS COWLEY SHOCK TRAUMA CENTER

47. R ADAMS COWLEY SHOCK TRAUMA CENTER
Case # 4
• 18-year-old male, drowning
• 10 minutes submerged, water temperature ~
22 o C
• ROSC after 50 minutes of CPR
• Therapeutic hypothermia started in ED

48. R ADAMS COWLEY SHOCK TRAUMA CENTER
7.16/69/57/-5
PCV 35 / 18 / 100% FiO2

49. Case # 4
• Cannulate?
–“for potential organ donation?”

50. R ADAMS COWLEY SHOCK TRAUMA CENTER
Thank you!
sgalvagno@som.umaryland.edu

51. • Michaels AJ et al. Extracorporeal life support in pulmonary failure after trauma. J
Trauma 1999;46:638-45.
• Cordell-Smith JA et al. Traumatic lung injury treated by extracorporeal membrane
oxygeantion (ECMO). Injury 2006;37:29-32.
• Biderman P et al. Extracorporeal life support in patients with multiple injuries and
severe respiratory failure: a single-center experience? J Trauma Cute Care
Surg 2013;75:907-12.
• Ried et al. Extracorporeal lung support in trauma patients with severe chest injury
and acute lung failure: a 10-year institutional experience. Crit Care 2013;17:R110.
• Guirand et al. Venovenous extracorporeal life support improves survival in adult
trauma patients with acute hypoxemic respiratory failure: a multicenter
retrospective cohort study. J Trauma Acute Care Surg 2014;76:1275-1281.
• Wu et al. Use of extracorporeal membrane oxygenation in severe traumatic lung
injury with respiratory failure. AJEM 2015;33:658-662.
• Bosarge et al. Early initiation of extracorporeal membrane oxygenation improves
survival in adult trauma patients with severe adult respiratory distress syndrome. J
Trauma Acute Care Surg 2016;81:236-243.
• Ahmad et al. Extracorporeal membrane oxygenation after traumatic injury. J
Trauma Acute Care Surg 2017;82:587-591.
ECMO as part of Trauma Care

52. • Robba et al. ECMO fro adult ARDS in trauma patients: a case series and systemic
literature review. J Trauma Acute Care Surg. 2017;82: 165–173
• Zonies D. ECLS in Trauma: Practical application and a review of current status. World
J Surg 2017;41:1159–1164
• Burke et al. ECLS is safe in trauma patients. Injury Int. J. Care Injured 2017;48:121–
126.
• Ainsworth et al. Revisiting extracorporeal membrane oxygenation for ARDS in
burns: A case series and review of the literature. Burns 2018;44:1433-1438.
• Wu et al. Predictors of hospital mortality in adult trauma patients receiving
extracorporeal membrane oxygenation for advanced life support: a retrospective
cohort study. Scand J Trauma Resusc Emerg Med 2018;26(1):14.
• Della Torre et al. Extra corporeal membrane oxygenation in the critical trauma
patient. Curr Opin Anaesthiol 2019;32:234-241.
• Hu et al. National estimates of the use and outcomes of extracorporeal membrane
oxygenation after acute trauma. Trauma Surg Acute Care Open 2019.
• Kruit et al. Assessment of safety and bleeding risk in the use of ECMO for multi-
trauma patients: A multicentre review. Journal of Trauma and Acute Care Surgery
2019 [PAP]
• Wang et al. Severe thoracic trauma caused left pneumonectomy complicated by
right traumatic wet lung, reversed by extracorporeal membrane oxygenation
support—a case report. BMC Pulmonary Medicine 2019;19:30.
ECMO as part of Trauma Care

53. R ADAMS COWLEY SHOCK TRAUMA CENTER
AJRCCM 2014;189:1374-1382
Respiratory Extracorporeal
Membrane Oxygenating Survival
Predictions Score (RESP)

54. R ADAMS COWLEY SHOCK TRAUMA CENTERCritical Care 2017;21:301
PRESET-Score