Extracorporeal cardiopulmonary resuscitation in patients with traumatic cardiac arrest during the acute phase following injury: a comprehensive systematic review and meta-analysis

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) is considered infeasible in patients with traumatic cardiac arrest (TCA).

METHODS: We conducted a systematic literature review applying a multi-layered search strategy to summarise and meta-analyse published evidence on the use of ECPR in TCA patients. We focused on TCA occurring during the pre-hospital and early in-hospital phase approximately corresponding to the first six hours following injury.

RESULTS: Nine studies (retrospective study, n = 4; case series, n = 2; case report, n = 3) including 84 TCA patients undergoing ECPR were identified. All ECPR procedures were performed in-hospital. The median age was 39 (29-51) years. Two patients (2%) were < 18 years. Sixty-seven (80%) patients were male. The injury mechanism was blunt in 54% and penetrating in 46%. Thirty-three (39%) patients survived to hospital discharge. All survivors recovered completely or with minor to moderate neurological disability. Survivors more frequently sustained TCA due to respiratory failure (56 vs. 18%, p = 0.008), experienced TCA out-of-hospital (36 vs. 14%, p = 0.04), had a shorter duration of cardiopulmonary resuscitation before ECPR [43 (25-71) vs. 78 (54-103) minutes, p = 0.02] and underwent surgery following ECPR more often (100 vs. 0%, p = 0.001) than non-survivors. While all survivors sustained chest injuries, no patient with traumatic brain injuries survived. The median initial extracorporeal blood flow reported in twenty-six patients was 3.6 (2.8-4.0) L/min. One study reported infeasibility to maintain adequate extracorporeal blood flows in four of eleven (36%) patients. While 21 of 27 patients (74%) received no initial anticoagulation, unfractionated heparin was administered in the remaining six patients. Of the 32 patients, in whom complications were reported, 18 subjects (56%) experienced one or more complications. Complications related to the extracorporeal circuit (25%) and neurological (22%), renal (16%), haemorrhagic (16%) and cardiovascular (16%) complications were reported most frequently.

CONCLUSIONS: This comprehensive systematic review of the literature identified 84 patients, who were treated with ECPR because of a TCA during the acute phase following injury. The results of this meta-analysis are hypothesis-generating and suggest that ECPR may be feasible and potentially beneficial in selected patients with TCA. Future research on ECPR in TCA is warranted. Entry of respective cases into international registries appears essential.