FRACTURE AND TRAUMA-RELATED RESPIRATORY FAILURE: THE USE OF EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) IN AN ADULT TRAUMA SERIES.

Abstract

Adult polytrauma patients are at high risk of developing acute lung injury. Fat embolism or traumatic pulmonary contusions are the usual causes and respiratory support is often indicated. Conventional treatment with intubation and positive pressure ventilation is sufficient for most patients with moderate lung injury. However, for patients with acute severe respiratory failure who remain hypoxic despite maximal pressure ventilation, the mortality rate exceeds 60%.

We have reviewed the use of extracorporeal membrane oxygenation (ECMO) in adult trauma patients with acute severe respiratory failure. ECMO was performed at a tertiary unit in an intensive care setting. Using an external oxygenation circuit the injured lungs were “rested” until pulmonary function recovered. With this method ventilation pressures could be reduced and ventilator-related pulmonary barotrauma was limited.

Between 1992 and 2000, 28 adult trauma patients were referred for ECMO. This group of patients were at the severe end of the ARDS spectrum with an average Murray Lung Injury score of 3.2. The most common injuries included long bone or pelvic fractures, and blunt chest trauma. Over 50% of patients with long bone fractures treated with ECMO had developed respiratory failure following internal fixation.

Overall survival was 71.4%. Statistical analysis demonstrated that outcome was not related to age, injury severity score, ECMO duration or the degree of lung injury as classified by the Murray scoring system. Mortality was usually a consequence of trauma-related sepsis or cardiogenic failure. Although the study group is small due to the relatively small number of referral, we believe that ECMO may confer a survival advantage. Since orthopaedic surgeons often play a pivotal role in the management of the patient with multiple injuries and are also increasingly involved in their intensive care therapy, we feel an awareness of this technique could offer benefit to a predominantly young healthy population.