Background: The risk of infections in acute trauma patients receiving extracorporeal membrane oxygenation (ECMO) has not been well defined, but this population is among the sickest in the hospital. This study characterizes the blood and respiratory pathogens in trauma patients receiving ECMO and tests the hypothesis that trauma patients receiving ECMO pose a unique risk for nosocomial infections. Methods: All trauma patients (n = 50) who required ECMO at a level 1 trauma center between July 2014 and September 2023 were retrospectively reviewed. Blood and respiratory samples were examined for pathogens. Burn injuries were excluded from this study. Results: Most were male (88%) and sustained blunt injuries (60%), of which the most common mechanism was motor vehicle collision (37%). The median intensive care unit (ICU) length of stay was 26 days (interquartile range [IQR]: 12-54), median ventilator days was 22 (IQR: 9-51), and median length of ECMO treatment was eight days (IQR: 4-18). The most common ECMO type was veno-venous (80%). Blood stream and/or respiratory infections were detected in 22 (44%) patients. The most common was respiratory infection (70.2%). Gram-negative pathogens were most common in both blood stream (53.3%) and respiratory infections (75%). Among the blood stream pathogens, 20% were multi-drug resistant. Among the respiratory pathogens, 41.7% were multi-drug resistant. The median number of days from ECMO cannulation to blood stream infection was 10 days (IQR: 4-16) and the median number of days to respiratory infection was seven days (IQR: 3-11). Mortality was 22.7% (n = 5) among patients who had a respiratory and/or blood stream infection and 60% (n = 17) in ECMO patients who had no infection (p = 0.007). Conclusion: Almost half of trauma patients receiving ECMO had nosocomial infections, which is comparable with the infection rate of trauma patients in the ICU not on ECMO. Larger studies are needed to further assess infection risk in these patients and provide guidelines to mitigate this risk.

There is increasing evidence that use of ECMO is beneficial in major trauma patients with refractory organ failure. Hence, increased numbers of ECMO support following major trauma are reported. We set out to determine the use of ECMO among major trauma patients submitted to the TraumaRegister DGUr® as well as patient features associated with ECMO support.

The TraumaRegister DGU® is a multinational database compiling trauma related health care data from point-of-injury, initial and critical care to outcome. Major trauma cases (AIS ≥ 3 irrespective of injury location) with subsequent critical care as well as respiratory and/or circulatory failure (SOFA score ≥ 3 per respective category) enrolled in the TraumaRegister DGU® between 2015 and 2022 were reviewed. A logistic regression model was carried out to evaluate patient features associated with ECMO support.

410/ 22,548 individuals (1.8%) received ECMO support. Survival among ECMO patients was 46.1%. At discharge, good functional outcome as indicated by a Glasgow outcome scale > 3 was observed for 97 ECMO patients (23.6%). Age > 65 (OR 95%-CI 1.90, 1.52-2.60), male sex (OR 1.49, 95%-CI 1.41-1.95), coagulopathy at admission to the emergency department (OR 2.37, 95%-CI 1.88-3.00), chest trauma (OR 2.12, 95%-CI 1.61-2.81), sepsis (OR 2.94, 95%-CI 1.93-2.97), as well as massive transfusion (OR 2.23, 95%-CI1.56-3.19) were associated with the use of ECMO following trauma.

In the TraumaRegister DGU®, ECMO for trauma related organ failure remains rare. Among ECMO patients, good functional outcome was observed infrequently. However, the design of the registry did not allow for capturing granular data on ECMO management and timing of organ failure. Hence, outcome data should be interpreted with caution. Nevertheless, evaluation of factors associated with ECMO support after trauma might contribute to early identification of ECMO candidates and improve patient distribution for trauma centers without ECMO capability.

Venovenous extracorporeal membrane oxygenation (VV ECMO) has been used for medical etiologies of acute respiratory distress syndrome refractory to conventional management. More recently, VV ECMO has been used to stabilize trauma patients with acute lung injury. We hypothesize that patients with traumatic injuries requiring VV ECMO have similar survival outcomes and describe the characteristics between the two populations.

This single-center, retrospective cohort study included all trauma and nontrauma patients in an 8-year period who were placed on VV ECMO. Cannulation decisions were made via multidisciplinary discussions between two intensivists and a trauma surgeon. Data were analyzed with descriptive statistics and regression analysis. After testing for normality, significance was defined as a p < 0.05.

A total of 516 patients were identified (438 nontrauma and 78 trauma VV ECMO patients). The trauma patient, defined as undergoing cannulation during initial trauma admission, had a median age of 29 years with 81% of patients being male, while the nontrauma patient had a median age of 41 years with 64% being males. Trauma VV ECMO patients had shorter ECMO courses (216 hours vs. 372 hours, p < 0.001), earlier cannulation (8 hours vs. 120 hours, p < 0.001), higher lactic acid levels precannulation (4.2 mmol/L vs. 2.3 mmol/L, p < 0.001), higher Sequential Organ Failure Assessment scores (13 vs. 11, p = 0.001), and higher Simplified Acute Physiology Scores II (63 vs. 48, p < 0.001). There was no difference in bleeding complications. Survival to discharge rates were similar between trauma and nontrauma VV ECMO groups (69% vs. 71%, p = 0.81).

This study demonstrates that trauma VV ECMO patients have higher markers of severe illness/injury when compared with their nontrauma VV ECMO counterparts yet have similar survival rates and shorter ECMO runs. Venovenous extracorporeal membrane oxygenation in trauma patients is a useful treatment modality for refractory hypoxemia, respiratory acidosis, and stabilization because of acute lung and thoracic injury.

Therapeutic/Care Management; Level IV.

Extracorporeal membrane oxygenation (ECMO) has emerged as a critical intervention in the management of patients with trauma-induced cardiorespiratory failure. This study aims to compare outcomes in patients with severe thoracic injuries with and without venovenous extracorporeal membrane oxygenation (VV-ECMO).

We performed a retrospective cohort study on Trauma Quality Improvement Program (2017-2021) and included all patients with isolated blunt thoracic injuries with Abbreviated Injury Scale score of ≥4 who required intubation. Patients were divided into two groups based on VV-ECMO and were compared using propensity score matching with the primary outcome of mortality.

A total of 14,106 patients with severe thoracic injuries were identified. Propensity score matching resulted in two groups of 812 VV-ECMO and 812 non-VV-ECMO groups. Venovenous ECMO group had significantly lower in-hospital mortality rates (22.3% vs. 37.3%, p < 0.001). However, VV-ECMO group had significantly higher rates of complications including cardiac arrest (27.7% vs. 10.6%), pulmonary embolism (7.6% vs. 2.1%), ventilator-associated pneumonia (16.7% vs. 4.2%), unplanned intubation (11.9% vs. 8.5%), unplanned intensive care unit (ICU) admission (8.4% vs. 4.9%), and unplanned return to operation room (10.1% vs. 2.6%) ( p < 0.001, for all). Patients in VV-ECMO group had significantly higher hospital (29.46 ± 26.37 vs. 13.59 ± 13.3 days) and ICU (22.96 ± 19.38 vs. 9.38 ± 9.05 days) length of stay ( p < 0.001, for both). In VV-ECMO group, the mean ± SD time to perform VV-ECMO was 5.54 ± 5.91 days. Each day earlier initiation of VV-ECMO resulted in decreased hospital and ICU length of stay by 67.1% and 59.9%, respectively ( p < 0.001 for both). Among patients without acute respiratory distress syndrome (n = 435 in each group after repeated PS matching), we observed significantly lower mortality rates in VV-ECMO group (26.9% vs. 40%, p < 0.001).

While VV-ECMO in isolated blunt thoracic trauma patients is associated with higher survival rates even in non-acute respiratory distress syndrome cases, it is associated with higher incidence of complications. These findings emphasize earlier consideration of VV-ECMO in severe blunt thoracic trauma.

Therapeutic/Care Management; Level III.

Special conditions, though not typically associated with cardiovascular distress, may be considered for treatment with temporary mechanical circulatory support (tMCS) devices. Such non-classical examples of cardiovascular compromise include trauma, sepsis, and peri-partum cardiomyopathy, among others, and may require urgent treatment with a tMCS device for haemodynamic stabilization and tentatively saving the patient's life. In this section, examples of the use of tMCS in several special circumstances are presented to garner awareness for such conditions, which have previously been overlooked or even considered contraindications, and highlight the benefit of tMCS devices during treatment of these patients and the need for more research into these circumstances.

Multimodality neuromonitoring represents a crucial cornerstone for patient management after acute brain injury. Despite the potential of multimodality neuromonitoring (particularly high-resolution neuromonitoring data) to transform care, its full benefits are not yet universally realized. There remains a critical need to integrate the interpretation of complex patterns and indices into the real-time clinical decision-making processes. This requires a multidisciplinary approach, to evaluate and discuss the implications of observed patterns in a timely manner, ideally in close temporal proximity to their occurrence. Such a collaborative effort could enable clinicians to harness the full potential of multimodal data. In this educational case-based scoping review, we aim to provide clinicians, researchers, and healthcare professionals with detailed, compelling examples of potential applications of multimodality neuromonitoring, focused on high-resolution modalities within the field of traumatic brain injury. This case series showcases how neuromonitoring modalities such as intracranial pressure, brain tissue oxygenation, near-infrared spectroscopy, and transcranial Doppler can be integrated with cerebral microdialysis, neuroimaging and systemic physiology monitoring. The aim is to demonstrate the value of a multimodal approach based on high-resolution data and derived indices integrated in one monitoring tool, allowing for the improvement of diagnosis, monitoring, and treatment of patients with traumatic brain injury. For this purpose, key concepts are covered, and various cases have been described to illustrate how to make the most of this advanced monitoring technology.

Over the past two decades, extracorporeal membrane oxygenation (ECMO) has been increasingly used to support critical patients with cardiac and respiratory failure who fail to respond to conventional management. In refractory cardiac arrest, ECMO can restore perfusion in patients who meet specific criteria designed to maximize survival benefit and good neurological outcomes. In recent literature, there is no report of mobile ECMO in a case of prolonged cardiac arrest with direct cardiac massage. We describe our experience with a 34-year-old man with multiple traumatic injuries following a motor vehicle collision. He was treated in a trauma center hospital in the same city as our center. He was initially in stable condition (spontaneous ventilation with FiO2 0.21, no vasoactive drugs, Glasgow 15, no acute kidney injury or other organ dysfunction). One week after admission, a retained left hemopneumothorax required surgical intervention, as previous drainage was ineffective. Computed tomography imaging was also concerning for parencyhmal injury by the thoracotomy tube. Intraoperatively, when the patient was placed in lateral position, he experienced cardiac arrest, presumed to be secondary to pulmonary embolism. After 18 min, we were asked to rescue this patient with ECMO, as he had no contraindications to support. After 81 min of advanced life support, including direct cardiac massage, return of spontaneous circulation was achieved seconds after ECMO was initiated. He was then transported to our hospital. The patient achieved a favorable neurological outcome (Glasgow Coma Scale score of 15 at 24 h) and was discharged after a 2 month stay. This case highlights the potential benefits of prolonged cardiopulmonary resuscitation and ECMO in patients with refractory in-hospital cardiac arrest. In this case, proper ACLS and CPR allowed time for mobile ECMO support to be initiated from a remote center.

Globally, trauma is a leading cause of death in young adults. The use of extracorporeal membrane oxygenation (ECMO) in the trauma population remains controversial due to the limited published research. This study aimed to analyze 30-day survival of all the trauma ECMO patients at our center, with respect to injury severity score (ISS) and new injury severity score (NISS).

We performed a retrospective analysis of all trauma patients receiving ECMO support at a Level 1 trauma center in Sweden between 1997 and 2019.

A total of 53 trauma patients received ECMO support. 85% were male; the median age was 24, with interquartile range (IQR) 17-44 years. More than 70% were multi-trauma patients. The mean NISS and ISS were 50 (IQR:34-57) and 42 (IQR:33-57), respectively. 62% were supported on veno-arterial ECMO with a survival benefit for veno-venous ECMO (75% vs. 36%, respectively (p = 0.01)). There was no association between severity in terms of trauma-score and survival. Sixteen patients (30%) were cannulated at referring hospitals and transported to our unit on ECMO with a survival of 69%, similar to those cannulated in-house. 60% of patients survived ECMO, and 51% survived to hospital discharge.

This study indicates that trauma patients may benefit from ECMO, independent of severity. Furthermore, our results support ECMO transport as feasible in trauma patients. We recommend larger multi-center studies to determine which trauma patients would have the greatest benefit of ECMO.

Extracorporeal membrane oxygenation (ECMO) has emerged as a salvage therapy in refractory respiratory failure. Within the literature, there is evidence to support the use of ECMO in severe thoracic trauma; however, there is minimal information on its applicability in mild to moderate thoracic trauma. This report describes a man in his 50s who suffered thoracic trauma following a motor vehicle accident, who, despite maximal medical therapy, experienced deterioration in respiratory function, requiring the commencement of veno-venous ECMO on day 5 post injury and subsequently achieved excellent functional recovery.

Extracorporeal membrane oxygenation (ECMO), an advanced life support method, was developed to treat severe cardiac and pulmonary failure in critically ill patients. ECMO was previously used to treat ARDS, cardiogenic shock, and after heart or lung transplant. It has since become a versatile therapeutic and surgical tool. When conventional methods fail, this technique works well for high-risk procedures such as tracheal resections, ventricular tachycardia ablations, and complicated percutaneous coronary interventions. These uses demonstrate ECMO's ability to oxygenate and stabilize the hemodynamics in challenging clinical circumstances. Clinical studies report survival rates exceeding 60% in ECMO-assisted thoracic surgeries, underscoring its efficacy in these settings. Recent advancements, such as portable ECMO systems and artificial intelligence-driven management tools, have further enhanced the safety and effectiveness of ECMO, enabling its use in diverse clinical environments. However, challenges remain, particularly in patient selection, resource allocation, and addressing ethical dilemmas. The integration of standardized protocols and technological innovations has mitigated complications such as vascular injury and infection, contributing to improved patient outcomes. This review examines ECMO applications and integration into multidisciplinary care, its configurations, and its growing role outside the intensive care unit in elective thoracic and cardiac surgery, trauma, and non-cardiac high-risk procedures.

Patients with severe traumatic brain injury (TBI) are at an increased risk of respiratory failure refractory to traditional therapies. The safety of extracorporeal membrane oxygenation (ECMO) in this population remains unclear. We aimed to examine outcomes following ECMO compared with traditional management in severe TBI patients.

We performed a retrospective cohort study using the Trauma Quality Improvement Program (2017-2020). We identified patients 18 years or older with severe TBI (Abbreviated Injury Score head, ≥3) who underwent ECMO or had either in-hospital cardiac or acute respiratory distress syndrome during their hospitalization. The study excluded pPatients who arrived without signs of life, had a prehospital cardiac arrest, had an unsurvivable injury, were transferred out within 48 hours of arrival, or were received as a transfer and died within 12 hours of arrival Patients with missing information regarding in-hospital mortality were also excluded. Outcomes included mortality, in-hospital complications, and intensive care unit length of stay. To account for patient and injury characteristics, we used 1:1 propensity matching. We performed a subgroup analysis among ECMO patients, comparing patients who received anticoagulants with those who did not.

We identified 10,065 patients, of whom 221 (2.2%) underwent ECMO. In the propensity-matched sample of 134 pairs, there was no difference in mortality. Extracorporeal membrane oxygenation was associated with a higher incidence of cerebrovascular accidents (9% vs. 1%, p = 0.006) and a lower incidence of ventilator-associated pneumonia. In the subgroup analysis of 64 matched pairs, patients receiving anticoagulation had lower mortality, higher unplanned return to the operating room, and longer duration of ventilation and intensive care unit length of stay.

Extracorporeal membrane oxygenation use in severe TBI patients was not associated with higher mortality and should be considered a potential intervention in this patient population. Systemic anticoagulation showed mortality benefit, but further work is required to elucidate the impact on neurological outcomes, and the appropriate dosing and timing of anticoagulation.

Therapeutic/Care Management; Level III.

High-energy blunt thoracic trauma is a highly morbid condition. When a pneumonectomy is required in such a setting, the mortality rate increases significantly. Here, we present a case of a motor vehicular crash (MVC) in which the patient suffered bilateral bronchial injuries requiring emergent thoracotomy, pneumonectomy, bronchial stenting, and initiation of venovenous extracorporeal membrane oxygenation (VV ECMO). The patient ultimately survived his injuries and was able to fully recover. We review the relevant literature in regard to the use of pulmonary stenting and VV ECMO in the setting of thoracic trauma management.

Retrohepatic inferior vena cava (IVC) injuries remain among the most lethal and serious liver injuries. Gauze packing is currently the first choice for IVC injuries; however, laparotomy itself poses the risk of circulatory collapse. Thus, less invasive treatment strategies are needed.

In this study, we conducted an animal experiment to replicate and validate successful treatments for an actual case of retrohepatic IVC injury that we had encountered.

A woman in her 80s presented to our hospital due to cardiac arrest caused by a pulmonary artery embolism. Venoarterial extracorporeal membrane oxygenation (ECMO) was introduced, and the patient was resuscitated. After resuscitation, contrast-enhanced CT revealed liver and retrohepatic IVC injuries, possibly caused by chest compressions. Liver injury was treated using transarterial embolization of the left hepatic artery. To treat the retrohepatic IVC injury, ECMO flow was increased to enhance the negative drainage pressure. The extravasation of the contrast medium had resolved in IVC angiography, and we opted for nonoperative management. The patient's hemodynamic status gradually stabilized, and ECMO was withdrawn on day 6. We confirmed these findings in a dog model of retrohepatic IVC injury.

Our findings from the patient and the animal model suggest that the flow diversion effect of ECMO can effectively manage active bleeding from the IVC by inserting a drainage cannula across the injured lesion. We think this procedure represents a novel treatment option for retrohepatic IVC injuries.

Cerebral microbleeds (CMBs) are common and varied in patients receiving extracorporeal membrane oxygenation (ECMO). Here, the authors describe CMB findings in patients receiving ECMO and their association with clinical factors.

A total of 138 patients receiving ECMO were enrolled and categorized as venovenous and venoarterial. Blood coagulation profiles during ECMO support and Glasgow Coma Scale (GCS) scores within 7 days were recorded. Patients with CMBs exhibited prolonged activated clotting time (P<0.001), decreased fibrinogen levels (P<0.001), reduced platelet counts (P<0.001), and extended prothrombin time (P<0.001). A significant correlation (P<0.05) was observed between the presence of CMBs and most coagulation parameters among all patients. Patients with venoarterial ECMO had significantly higher activated partial thromboplastin time, activated clotting time, and prothrombin time compared with those with venovenous ECMO (all P<0.05). Patients with a less severe CMB burden exhibited higher GCS scores and better neurological injury outcomes at both 7 and 90 days. CMB burden in all patients with ECMO was significantly correlated (P<0.05) with most blood coagulation profiles and neurological injury.

CMB burdens after ECMO are common, varied, and associated with a variety of clinical conditions. These findings may guide ECMO management.

Extracorporeal membrane oxygenation (ECMO) can provide temporary circulatory support and vital organ oxygenation and is potentially useful as a bridge therapy in some trauma cases. We aimed to demonstrate the characteristics and outcomes of patients with trauma treated with veno-arterial ECMO (V-A ECMO) using data from a Japanese nationwide trauma registry.

This retrospective descriptive study analyzed data from the Japan Trauma Data Bank between January 2019 and December 2021. Patients with severe trauma (injury severity score [ISS] ≥ 9) and treated using V-A ECMO were assessed.

Among the 72,439 patients with severe trauma, 51 received V-A ECMO. Sixteen patients (31.3%) survived until hospital discharge. On hospital arrival, six (37.5%) survivors and 15 (42.9%) non-survivors experienced cardiac arrest. The median ISS for the survivor and non-survivor group was 25 (range, 25-39) and 25 (range, 17-33), respectively. Thoracic trauma was the most common type of trauma in both groups. In the non-survivor group, open-chest cardiopulmonary resuscitation, aortic cross-clamping, and resuscitative endovascular balloon occlusion of the aorta were performed in 10 (28.6%), 5 (14.3%), and 4 (11.4%) patients, respectively. However, these procedures were not performed in the survivor group. Peripheral oxygen saturation tended to be lower in the survivor group both before and upon arrival at the hospital.

The results of this study suggest the potential benefit of V-A ECMO in some challenging trauma cases. Further studies are warranted to assess the indications for V-A ECMO in patients with trauma.

Advances in medical technology have begun to blur the lines between life and death as well as the lines between appropriate and inappropriate therapy. This review addresses the charged issue of the management of cardiac devices at or near the end of a patient's life, provides a summary of prior and current opinion with some historical context, and attempts to provide some modest guidance as to how to approach the various options to the patient's best advantage. Modalities to be addressed include indwelling electronic devices, the left ventricular assistance device, and extracorporeal mechanical oxygenation, and includes available outcome data as well as ethical analysis from a number of commentators. The expected further increase in technical sophistication of these devices is expected to render the various aspects of device deactivation more and more complex over the course of the next few years such that careful attention to and knowledge about this issue will continue to be more and more necessary.

Penetrating thoracic injuries have a significant risk of morbi-mortality. Despite the advancements in damage control methods, a subset of patients with severe pulmonary vascular lesions and bronchial injuries persists. In some of these cases, post-traumatic pneumonectomy is required, and perioperative extracorporeal membrane oxygenation (ECMO) support may be required due to right ventricular failure and respiratory failure.

A male was brought to the emergency department (ED) with a penetrating thoracic injury, presenting with massive right hemothorax and active bleeding that required ligation of the right pulmonary hilum to control the bleeding. Subsequently, he developed right ventricular dysfunction and ARDS, necessitating a dynamic hybrid ECMO configuration to support his condition and facilitate recovery.

Penetrating thoracic injuries with severe pulmonary vascular lesions may need pneumonectomy to control bleeding. ECMO support reduces the associated mortality by decreasing the complications rate. A multidisciplinary team is essential to achieve good outcomes in severe compromised patients.

Critical care principles and techniques continue to hold promise for improving patient outcomes in time-dependent diseases encountered by emergency medical services such as cardiac arrest, acute ischemic stroke, and hemorrhagic shock. In this review, the authors discuss several current and evolving advanced critical care modalities, including extracorporeal cardiopulmonary resuscitation, resuscitative endovascular occlusion of the aorta, prehospital thrombolytics for acute ischemic stroke, and low-titer group O whole blood for trauma patients. Two important critical care monitoring technologies-capnography and ultrasound-are also briefly discussed.

This review covers key elements of the critical care management of patients with thoracic trauma. Contrast-enhanced chest computertomography remains the diagnostic modality of choice, as it is more sensitive than conventional chest imaging. Regarding risk stratification, special caution is required in older patients with thoracic trauma given their high risk for posttraumatic complications. In the case of respiratory insufficiency, an attempt of non-invasive ventilation techniques is justified in most patients due to potential treatment benefits. Achieving sufficient pain control is a fundamental goal of critical care management. In this regard, erector-spinae-block and paravertebral block present potentially advantageous alternatives to thoracic epidural anaesthesia. In stable patients, the placement of small-calibre chest tubes may be a beneficial approach compared with large-bore tubes. If surgical stabilization of rib fractures is indicated, it should be done as early as possible.

Extracorporeal membrane oxygenation (ECMO) has evolved into a pivotal intervention in critical care, offering a lifeline for patients facing severe respiratory or cardiac failure. This review provides a comprehensive exploration of ECMO, spanning its definition and historical background to its contemporary advancements and ongoing impact in critical care. The versatility of ECMO in addressing diverse critical conditions, careful patient selection criteria, and the nuanced management of complications are discussed. Advances in technology, including miniaturization, novel circuit designs, and the integration of remote monitoring, showcase the evolving landscape of ECMO. The review underscores the ongoing impact of ECMO in improving survival rates, enhancing mobility, and enabling remote expertise. As a symbol of hope and innovation, ECMO's lifesaving potential is evident in its ability to navigate the complexities of critical care and redefine the boundaries of life support interventions.