Extracorporeal Cardio-Pulmonary Resuscitation (E-CPR) in Traumatic Cardiac Arrests Caused by Penetrating Thoracic Injuries: A Series of Two Cases
Keywords:Thoracic injury, ECMO, Cardio-pulmonary resuscitation, Cannulation, Endovascular trauma management
Background. We present two cases of thoracic penetrating injuries that necessitated extracorporeal cardiopulmonary resuscitation (E-CPR).
Patients.Two male patients were admitted to hospital within 20-25 minutes; one a chest stab wound and the other a gunshot injury. Upon ongoing CPR, patient #1 underwent resuscitative sternotomy. Bleeding from a right ventricle injury was controlled, but cardiac arrest (CA) re-occurred. Patient #2 underwent immediate surgery due to multiple rib fractures and massive hemopneumothorax, and experienced multiple CAs. Due to refractory asystole with ongoing CPR, ECMO was initiated after 100 and 135 minutes, respectively. Primary lactate level in case #1 and #2 was 8 and 20 mmol/L, respectively.
Results. In both cases, femoral artery (17-19Fr) and vein (25-27Fr) were cannulated and connected to the Maquet ECMO circuit with a flow rate of 4-5 L/min. In both cases, ROSC was achieved within 20 minutes after ECMO initiation with relative stabilization of mean arterial pressure: 50-60 and >80 mmHg, respectively. In patient #1, postoperative bleeding necessitated re-thoracotomy and hemorrhage control. In patient #2, left pulmonectomy and ligation of intercostal arteries was performed. 12/30 units of red blood cells, 16/45 units of fresh frozen plasma, and 2/8 units of platelets were given in case #1/2, respectively. Lactate level increased to 25 mmol/L and decreased to 8 mmol/L in 5 hours, respectively. Both patients died in the ICU within 9 and 13 hours after admission due to bleeding.
Conclusion.Extracorporeal-CPR allows vital function protection even in traumatic CA, but necessitates appropriate resuscitation. If no bleeding control is achieved, then E-CPR is futile.