For patients who suffer a cardiac arrest from exsanguinating blood loss, survival rate is only 5–10%, even with rapid, advanced prehospital care, fluid resuscitation, and an emergency department thoracotomy. In his clinical session titled Saving Exsanguinating Trauma Patients with Hypothermia and Cardiopulmonary Bypass, which was held Friday, Feb. 26 at EMS Today 2016, Sam Tisherman, MD, said, “CPR just doesn’t work for trauma.” Because of these dismal results, guidelines for withholding or discontinuing resuscitative efforts in such patients have been developed and adopted by many EMS agencies.
Dr. Peter Safar, known as the father of CPR, and Col. Ron Bellamy of the U.S. Army, reviewed data from the Vietnam War that suggested some soldiers died over a period of 30–60 minutes with injuries that were technically repairable. They developed the concept that is now known as Emergency Preservation and Resuscitation (EPR) to, as Safar put it, “pickle” the patient long enough for a surgeon to stop the bleeding.
Tisherman reviewed the development of EPR. Very deep hypothermia (10oC) seems to be the best way to preserve the patient for up to one hour until hemostasis. But in the trauma world, Tisherman said, “people think this is blasphemy,” since colder trauma patients tend to do worse than those who stay warm. Tisherman pointed out, however, that there is a big difference between uncontrolled, exposure hypothermia and the controlled hypothermia used for EPR. Tisherman said, “We have tried a number of drugs for EPR, but none have had significant benefit over the cooling.”
Based upon extensive preclinical studies, Tisherman and colleagues are conducting a trial called Emergency Preservation for Cardiac Arrest from Trauma. Patients who suffer a cardiac arrest from penetrating trauma just before arrival to the hospital, or in the ED or OR, are eligible. If they don’t respond rapidly to standard resuscitation efforts, EPR can be initiated by rapidly pumping large volumes of ice-cold saline directly into the aorta. Because the body will be so cold, cardiopulmonary bypass will be required for delayed resuscitation after bleeding has been controlled.
Tisherman also reviewed:
- Conducting resuscitation research with an exception from informed consent
- Training for EPR
For more coverage of EMS Today 2016, click here.