Damage Control Resuscitation in Traumatic Hemorrhage: Comment

We read with great enthusiasm the manuscript by Richards et al. titled “Damage Control Resuscitation in Traumatic Hemorrhage: It Is More Than Fixing the Holes and Filling the Tank.”  This comprehensive review significantly contributes to our understanding of resuscitation strategies in traumatic hemorrhage, emphasizing the importance of a multifaceted approach to patient care.

While the manuscript effectively encapsulates various critical aspects of damage control resuscitation, we wish to highlight an area not extensively covered in the discussion—management strategies for patients experiencing the direst consequences of traumatic injuries, including exsanguination cardiac arrest and cardiac arrest caused by blunt cardiac injury, airway trauma, severe pulmonary contusion, and other causes of severe hypoxia. These scenarios necessitate familiarity with the latest advancements in emergency response techniques. Standard resuscitation techniques in these patients are unlikely to produce effective organ perfusion and often result in poor outcome, with mortality of nearly 100% reported for certain types of exsanguination cardiac arrest. For patients without exsanguination as the predominant reason for cardiac arrest, novel resuscitative efforts involving extracorporeal circulation may be required. The use of extracorporeal life support can result in a reasonable survival rate, with one study reporting a 70% survival.  Although venovenous–extracorporeal membrane oxygenation (ECMO) was employed in a majority of these cases (88.5%), 11.5% underwent venoarterial ECMO (standard venoarterial–ECMO or venoarterial–ECMO for extracorporeal cardiopulmonary resuscitation [CPR]). The authors reported a 50% survival in the patients who underwent conventional venoarterial–ECMO and 25% survival in patients who received extracorporeal CPR, in line with extracorporeal life support survival rates in nontrauma patients from the Extracorporeal Life Support organization registry (44% survival for non–extracorporeal CPR cardiac support and 30% survival for extracorporeal CPR).  These findings underscore that trauma should not be considered a contraindication for extracorporeal life support. Moreover, in trauma patients, where systemic anticoagulation is often not feasible, the use of heparin-coated circuits presents a tailored approach in navigating the challenges of associated hemorrhage and hypovolemia. While extracorporeal life support is not a direct treatment for hemorrhagic shock or exsanguination cardiac arrest, it can be a valuable tool in managing postresuscitative myocardial suppression from acidosis, hypothermia, electrolyte abnormalities, citrate toxicity, and transfusion-associated acute lung injury.

The innovative work by Tisherman et al.  on emergency preservation and resuscitation for exsanguination cardiac arrest introduces a pioneering approach to trauma care. Their feasibility study on emergency preservation and resuscitation utilizes profound hypothermia to extend the time available for surgical intervention before irreversible organ damage occurs, demonstrating significant improvements in survival and neurologic recovery.

For trauma patients with non-exsanguination cardiac arrest, extracorporeal CPR can offer a bridge to definitive care by providing circulatory and respiratory support when conventional CPR fails, ideally with cannulation and initiation occurring within 60 min of cardiac arrest. It helps in maintaining oxygenation and perfusion, potentially allowing for the treatment of reversible causes of cardiac arrest and improving the chances of survival and neurologic outcomes by reducing hypoxic or ischemic time of vital organs. In a recent review by Inoue et al.  the potential of extracorporeal CPR to mitigate reperfusion injury and secondary brain damage was highlighted, in addition to the increased chance of successful resuscitation and return of spontaneous circulation, underscoring the need for careful management and future integration of extracorporeal CPR with other therapeutic strategies.

As extracorporeal CPR programs expand, consideration should be provided to the disparities of care that exist currently, those that could be created or exacerbated by emergency preservation and resuscitation, and methods that may reduce existing disparities through extracorporeal CPR. For example, rural trauma victims have higher mortality than nonrural residents. One third of the U.S. population lives further than 45 min away from an ECMO-capable center, and 47% of children in a rural setting live greater than 60 miles from an ECMO-capable center.  Furthermore, application of extracorporeal CPR may be hindered by timely access to personnel skilled at cannulation and initiation of extracorporeal life support. In the absence of exsanguination, extracorporeal life support initiated at a rural or nontrauma center can serve to bridge the patient during transfer to a higher level of care and address current mortality disparities pertaining to patient distance to these centers.

In conclusion, the article by Richards et al. provides an invaluable overview of damage control resuscitation that can be complimented by integrating advancements in extracorporeal life support (including extracorporeal CPR) and emergency preservation and resuscitation (fig. 1). We look forward to seeing these critical aspects of trauma care addressed in future discussions and research.