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Extracorporeal life support in hypothermic cardiac arrest: Reconsidering trauma as an absolute contraindication

      Sir,
      We report a case of hypothermic cardiac arrest in a patient with strong clinical suspicion of severe traumatic brain injury to initiate a wider discussion on when eCPR should be attempted in hypothermic trauma patients.
      A seven year-old boy stumbled on a hiking path, slipped underneath the rope railing, fell 40 m into a canyon and was submersed in a cold mountain creek. It took at least 20 min before the boy was extracted. The rescue crew found him with an unobstructed airway, bradypneic and bradycardic with brachial pulses, GCS was 5. A bodycheck showed no injuries, his temperature was 24.4 °C. Soon, the patient developed a generalized tonic seizure and received 3 mg midazolam i.o. at an estimated body weight of 30 kg, was immobilized, intubated, and externally warmed. During landing at our trauma center, circulation deteriorated to PEA and CPR was initiated. We performed bilateral needle chest decompressions to rule out tension pneumothorax. Primary survey revealed a negative FAST, bilateral pulmonary edema compatible with fresh-water aspiration, an otherwise negative whole-body X-ray, and a right pupil larger than the left. We inserted bilateral chest drains, recorded a core temperature of 27.5 °C, an arterial pH of 7.3, potassium of 2.4 mmol/l and lactate of 4 mmol/l.
      A multi-disciplinary decision was made to institute eCPR with central cannulation. A minimized extracorporeal circulation (MiECC) system with a heparin-coated circuit was started without systemic heparin. At the start of cardiac surgery, the difference in pupil size increased. We suspected a growing intra-cranial hemorrhage and performed an exploratory burr hole
      • Eaton J.
      • Hanif A.B.
      • Mulima G.
      • Kajombo C.
      • Charles A.
      Outcomes following exploratory burr holes for traumatic brain injury in a resource poor setting.
      over the right frontal convexity concurrently. Intracranial opening pressure was 40 cm H2O. Forty milliliters of blood were removed from the epidural space. Intracranial pressure normalized thereafter, and pupils became equal again. The patient converted to sinus rhythm following one internal DC countershock (10 J) at a temperature of 29.2 °C. Pulmonary edema was evident with frothing from the endotracheal tube despite high PEEP. This prompted us to exchange the MiECC with a veno-arterial centrifugal pump ECMO to allow for protracted weaning at a core temperature of 34.0 °C. A postoperative CT revealed multiple intracranial concussion bleedings and remnants of a right frontal epidural hematoma, but no other traumatic injuries. Mild hypothermia was maintained for 14 h and the patient weaned from ECMO after a total of 48 h. Systemic heparin was withheld for the first 24 h; afterwards, we aimed for an activated clotting time of 170 s. At discharge on day 36, the boy retained a weakness in his right arm and a right-sided facial nerve paresis. Otherwise independently functional (CPC 2), he now interacts and plays normally.
      Despite encouraging case reports (Table 1), the role of ECLS and eCPR in hypothermic arrest patients with trauma is yet to be clarified. Our report and the comparably good neurological outcomes in hypothermic arrest patients overall
      • Saczkowski R.S.
      • Brown D.J.A.
      • Abu-Laban R.B.
      • Fradet G.
      • Schulze C.J.
      • Kuzak N.D.
      Prediction and risk stratification of survival in accidental hypothermia requiring extracorporeal life support: an individual patient data meta-analysis.
      suggest to reconsider trauma, and TBI in particular, as a general contraindication to ECLS. Existing algorithms should be further refined to account for trauma extent, location and consequences.
      Table 1Reports of trauma cases
      As reported in the original publication.
      with immediate use of extracorporeal life support (ECLS) or eCPR.
      PublicationPatient, trauma mechanismState on ED arrivalInjuries (and interventions where reported)Type of ECLS
      ECMO: extracorporeal membrane oxygenation. MiECC: minimized extracorporeal circulation. ECLS: extracorporeal life support. eCPR: extracorporeal cardiopulmonary resuscitation.
      Neurological Outcome
      Darocha et al.
      • Darocha T.
      • Kosiński S.
      • Jarosz A.
      • Drwila R.
      Extracorporeal rewarming from accidental hypothermia of patient with suspected trauma.
      Adult male, age unknown, found in streetHeart rate: 20/min, Temp: 25 °C, immediate CPR.Multiple rib fractures, Th6 vertebrae fracture, perihepatic and perisplenic fluid. Small pericerebral hematoma over right temporal and parietal lobe, fractures of right occipital and parietal bones, all attributed to previous craniotomyFemoral v-a ECMOCPC 1
      Winkler et al.
      • Winkler B.
      • Jenni H.J.
      • Gygax E.
      • et al.
      Minimally invasive extracorporeal circulation resuscitation in hypothermic cardiac arrest.
      59 year old male, 15 m mountain fallCPR. Temp: 25.3 °CBilateral serial rib fractures, dislocated right hip fracture and an open-book pelvic ring fracture (immediate external fixation) with active retroperitoneal bleeding (immediate embolization)Femoral v-a MiECCCPC 1, return to work as professional mountain guide
      Ting and Brown
      • Ting D.K.
      • Brown D.J.A.
      Use of extracorporeal life support for active rewarming in a hypothermic, nonarrested patient with multiple trauma.
      53 year old male, ejected from carHeart rate: 60/min, blood pressure: 60/39 mmHg, Temp: 23.5 °CC4–C5 ligamentous injury (eventual stabilization), severe frostbite to right hand (partial amputation of all digits eventually)Femoral v-a ECLSFull neurologic recovery
      This report7 year old boy, 40m fall into creek, submersedCPR. Temp: 27.5°CMultiple small intracranial concussion bleedings, small remnants of a right frontal epidural hematoma (after drainage through exploratory burr hole)Central MiECCCPC 2
      a As reported in the original publication.
      b ECMO: extracorporeal membrane oxygenation. MiECC: minimized extracorporeal circulation. ECLS: extracorporeal life support. eCPR: extracorporeal cardiopulmonary resuscitation.

      Conflict of interest statement

      WEH has received research funding from Mundipharma Medical Basel, CH, research support in kind from Prytime Medical Boerne, USA, support for a conference he chaired from Mundipharma Medical Basel, CH, Isabell Healthcare, UK, EBSCO, GER, and VisualDx, USA and speakers honorarium from AO Foundation Zurich, CH. BE has received speakeŕs honoraria from Medtronic Academia. MM has received research funding from Getinge Groupe. All other authors report no conflict of interest.
      The authors obtained patient and guardian consent to the publication of this report.

      References

        • Darocha T.
        • Kosiński S.
        • Jarosz A.
        • Drwila R.
        Extracorporeal rewarming from accidental hypothermia of patient with suspected trauma.
        Medicine (Baltimore). 2015; 94e1086https://doi.org/10.1097/MD.0000000000001086
        • Winkler B.
        • Jenni H.J.
        • Gygax E.
        • et al.
        Minimally invasive extracorporeal circulation resuscitation in hypothermic cardiac arrest.
        Perfusion. 2016; 31: 489-494https://doi.org/10.1177/0267659116636212
        • Ting D.K.
        • Brown D.J.A.
        Use of extracorporeal life support for active rewarming in a hypothermic, nonarrested patient with multiple trauma.
        Can Med Assoc J. 2018; 190: E718-21https://doi.org/10.1503/cmaj.180117
        • Eaton J.
        • Hanif A.B.
        • Mulima G.
        • Kajombo C.
        • Charles A.
        Outcomes following exploratory burr holes for traumatic brain injury in a resource poor setting.
        World Neurosurg. 2017; 105: 257-264https://doi.org/10.1016/j.wneu.2017.05.153
        • Saczkowski R.S.
        • Brown D.J.A.
        • Abu-Laban R.B.
        • Fradet G.
        • Schulze C.J.
        • Kuzak N.D.
        Prediction and risk stratification of survival in accidental hypothermia requiring extracorporeal life support: an individual patient data meta-analysis.
        Resuscitation. 2018; 127: 51-57https://doi.org/10.1016/j.resuscitation.2018.03.028