ECMO for the Trauma Patient: Challenges, Successes, and the Role of the Nurse

Jessica Hamilton, BSN, RN, CCRNECMO Program CoordinatorHarborview Medical CenterSeattle, WA

• To understand ECMO and how it is applied in trauma patients• To understand the role of the nurse in the initiation and daily

management of patients on ECMO• Begin to think about what it takes to start and maintain an ECMO

program and what complications you may run into

Learning Objectives

• No Disclosures

Disclosure Statement

What is ECMO?• Extracorporeal Membrane

Oxygenation • Extracorporeal Life Support• ECMO and ECLS are used

interchangeably• Two primary types of ECMO

• Veno venous (VV) • Veno arterial (VA)

Configurations• Veno venous (VV)

• Bypasses lungs• Removes CO2• Supplies Oxygen • No hemodynamic support• Drains from a vein• Returns to a vein

• Veno Arterial (VA)• Bypasses heart and lungs• Removes CO2• Supplies oxygen• Full hemodynamic support• Drains from a vein• Returns to the aorta

There are other configurations but, these two with peripheral cannulation are the most relevant to trauma patients

ECMO FOR TRAUMA IN 1971

ECMO For Trauma in 2018• Historically seen as futile, management and technology have

improved • Circuits now cause less hemolysis• Reduced anticoagulation needs• Less use of roller pumps = Less rupture• Percutaneous cannulation• Less ventilator days• Shorter hospital stays

Femoral Vein & ArteryIndications: Hypothermia, PE, Cardiogenic shock

Configuration VA

9

Configuration VV

10

How can ECMO be applied to trauma patients?• Hypothermic V-Fib arrest

• Exposure after trauma• Cold water drowning

• Massive PE after trauma• Chest wall crush• Blast injuries• Traumatic pneumonectomy • Blunt and penetrating trauma patients that develop ARDS

Who makes up an ECMO team• Surgeons or interventionists for cannulation• Daily management physician team• Perfusionist or circuit primer• Bedside RN and RT with ECMO training• ECMO specialist

Harborview’s ECMO team• No Perfusion department so RN/RT primers• RN/RT specialist model

• 4-7 specialists in house at all times• 40 hour didactic and hands on training • Routine skills practice

• Bedside nurses with 4 hour training• Respiratory therapists• Surgery Critical Care team cannulates and manages• Attendings and Fellows only – no residents at this time

Blast Injury – VV ECMO• 40 M Previously healthy, active duty, fighter pilot • Explosive decompression during ground testing of military

jet• Pulmonary contusions, lacerations and pneumatoceles• Nimbex, Flolan, LPV – continued downward trend• HD 3 – worsening ABG, poor oxygenation, air leaks from

chest tubes• 12 day VV ECMO run allowing for total lung rest• Trach capped HD 24• Discharged home HD 26

Blast injury – VV ECMO • 6 months later – deployed with full

clearance • Returned home 12/2018 after 8

months of counter-terrorism operations in N. Korea and the Middle East

• Training for a triathlon• Home with his three kids and wife• Now the commanding officer at

Weapons School aka“Top Gun”

GSW – VV ECMO• 18yo M – Multiple GSW

• T4 Para• Multiple rib fractures • Severe ARDS and VAP• LPV, Prone position, flolan, NMB all

attempted• HD 5 placed on ECMO for hypoxic

respiratory failure • VV ECMO for 42 days• To inpatient rehab HD 68• Spinal cord injury peer support champion

Hypothermia – VA ECMO• 21yo Female• Cold water drowning after boat capsized• 2+ hours of CPR• 25 degree core temp upon arrival• VA ECMO cannulation• Rewarmed to 33 then cardioverted• TTM x 36 hours• Paralytics off – Full neurological recovery• Discharge home on HD 7

Starting a program• Large upfront costs

• Equipment • Staff training• Call schedules• Practice and drills

• Patient selection • Clear inclusion and exclusion criteria• Plan for “creep”• Balancing mortality – too conservative vs too aggressive

• Reimbursement

Does your hospital need an ECMO program?• What facilities in your region already have a program in place?• What patient types do they treat?• Do they accept consults?

• Do they cannulate?• Do they transport?• When should you call?

• Will the numbers make sense?• Can your hospital afford the upfront costs?

Questions?

• To successfully complete this course, participants must attend the entire event and complete/submit the evaluation at the end of the session.

• Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Successful Completion