ECMO in Trauma: Expanding Indications

Sam Austin, DO
Surgical Critical Care Fellow
R Adams Cowley Shock Trauma Center

The first reported successful application of Extracorporeal Life Support (ECLS) in an adult took place in a 24-year-old male who experienced acute respiratory distress syndrome following multiple traumatic injuries in a motor vehicle collision. Dr. Hill described his use of the “Bramson Lung” in a patient maintained on ECLS for approximately 3 days and regaining complete restoration of lung function.¹ Applications of Extracorporeal Membrane Oxygenation (ECMO) have continued to expand before eyes, such as its use in extracorporeal cardiopulmonary resuscitation (eCPR), the deployment of mobile pre-hospital ECMO, and successful cannulations in public settings such as city streets (or the infamous case of a patient receiving eCPR in the Louvre). But as indications for ECMO continue to expand, its role in trauma at times remains unclear.

Bleeding and hemorrhage remain the largest concerns associated with the use of ECMO in trauma patients. Patients in hemorrhagic shock may encounter the feared “lethal triad”: coagulopathy, acidosis, and hypothermia. Despite its concurrent risk of bleeding, ECLS could potentially be of benefit in this scenario due to its ability to recover sufficient blood flow, rewarm through the circuit, and rapidly correct hypoxia. Furthermore, the downfall of conventional interventions for the critical trauma patient may contribute to the need for more advanced salvage therapies. For example, massive transfusions may cause significant pulmonary edema or transfusion-related acute lung injury, high ventilator settings can precipitate pulmonary barotrauma or ventilator-induced lung injury, and vasoactive/inotropic medications may result in myocardial dysfunction or limb/end-organ ischemia.

The utility of ECMO in trauma can be partially assessed by its feasibility and safety. In a previous retrospective analysis of patients with severe trauma who were managed on VV ECMO, 78% of cases had “successful” ECMO runs (defined as the ability to maintain adequate flow and patient perfusion) with 61% of patients surviving to hospital discharge. Factors most predictive of ECLS failure were severe acidosis and higher injury severity scores (ISS).² A three-year review of the use ECLS in trauma patients from the National Trauma Data Bank demonstrated similar findings in regard to survival and ISS association with mortality.³ In assessing the appropriate trauma patient for ECMO, the following factors should be considered: injury severity, time from injury, time on the ventilator, and time from meeting your institution’s ECMO “criteria”.^4-6

The most feared complication associated with the use of ECMO in trauma remains bleeding, including surgical site or cannula site bleeding, or spontaneous intracerebral hemorrhage.⁷ These bleeding risks may be further augmented by the need for systemic heparinization due to the concomitant risk of circuit and systemic thrombosis. This is of particular concern in critically ill trauma patients who are inherently at an elevated bleeding risk. Unsurprisingly, when ECLS has been used in hemorrhagic conditions, those managed initially without anticoagulation demonstrated the highest rate of clotting complications whereas those managed with some type of anticoagulant had the highest rate of bleeding complications.⁸ When specifically assessing trauma patients, ECMO use has not appeared to be associated with any major bleeding complications and bleeding or thrombosis risk has appeared to be independent of the use anticoagulation. Furthermore, the rate of new or worsening intracerebral hemorrhage has appeared to be independent of systemic anticoagulation.⁹

As we continue to gain more experience and comfort in managing this high-risk patient population, the benefit of ECMO in traumatic conditions, such as traumatic brain injury, traumatic pneumonectomy, and tracheal injury may become more apparent. For now, we continue to just scratch the surface of its role and benefit in trauma. 

References

1. Hill JD, O'Brien TG, Murray JJ, et al. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med. Mar 23 1972;286(12):629-34. doi:10.1056/NEJM197203232861204
2. Bonacchi M, Spina R, Torracchi L, Harmelin G, Sani G, Peris A. Extracorporeal life support in patients with severe trauma: an advanced treatment strategy for refractory clinical settings. J Thorac Cardiovasc Surg. Jun 2013;145(6):1617-26. doi:10.1016/j.jtcvs.2012.08.046
3. Burke CR, Crown A, Chan T, McMullan DM. Extracorporeal life support is safe in trauma patients. Injury. Jan 2017;48(1):121-126. doi:10.1016/j.injury.2016.11.008
4. Powell EK, Reynolds TS, Webb JK, et al. Early veno-venous extracorporeal membrane oxygenation is an effective strategy for traumatically injured patients presenting with refractory respiratory failure. J Trauma Acute Care Surg. Aug 1 2023;95(2S Suppl 1):S50-S59. doi:10.1097/TA.0000000000004057
5. Michaels AJ, Schriener RJ, Kolla S, et al. Extracorporeal life support in pulmonary failure after trauma. J Trauma. Apr 1999;46(4):638-45. doi:10.1097/00005373-199904000-00013
6. Li X, Hu M, Zheng R, et al. Delayed Initiation of ECMO Is Associated With Poor Outcomes in Patients With Severe COVID-19: A Multicenter Retrospective Cohort Study. Front Med (Lausanne). 2021;8:716086. doi:10.3389/fmed.2021.716086
7. ECMO Registry of the Extracorporeal Life Support Organization (ELSO).
8. Willers A, Swol J, Kowalewski M, et al. Extracorporeal Life Support in Hemorrhagic Conditions: A Systematic Review. ASAIO J. May 1 2021;67(5):476-484. doi:10.1097/MAT.0000000000001216
9. Kruit N, Prusak M, Miller M, Barrett N, Richardson C, Vuylsteke A. Assessment of safety and bleeding risk in the use of extracorporeal membrane oxygenation for multitrauma patients: A multicenter review. J Trauma Acute Care Surg. Jun 2019;86(6):967-973. doi:10.1097/TA.0000000000002242