Page 79 - 2020 JSOM Winter

Battlefield Extracorporeal Cardiopulmonary Resuscitation
for Out-of-Hospital Cardiac Arrest

A Feasibility Study During Military Exercises

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Viktor A. Reva, MD, PhD *; Alexander A. Pochtarnik, MD ; Daniil A. Shelukhin, MD, PhD ;
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Andrey E. Skvortzov, MD, PhD ; Evgeny A. Semenov, MD, PhD ; Alexander A. Emelyanov, MD ;
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Artem M. Nosov, MD, PhD ; Konstantin N. Demchenko, MD, PhD ; Oleg N. Reznik, MD, PhD ;
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Igor M. Samokhvalov, MD, PhD ; Joseph J. DuBose, MD 11
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ABSTRACT
Purpose: To evaluate the feasibility of prehospital extracor- Introduction
poreal cardiopulmonary resuscitation (E-CPR) in the military
exercise setting. Methods: Three 40kg Sus scrofa (wild swine) The avoidance of early mortality remains the primary focus of
underwent controlled 35% blood loss and administration of combat surgeons around the world. The main causes of poten-
potassium chloride to achieve cardiac arrest (CA). During CPR, tially preventable deaths—hemorrhage, airway obstruction,
initiated 1 minute after CA, the animals were transported to and tension pneumothorax—have been aggressively addressed
Role 1. Femoral vessels were cannulated, followed by E-CPR by TCCC and advanced resuscitative care (ARC) protocols to
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using a portable perfusion device. Crystalloid and blood trans- minimize mortality. Although a variety of solutions has been
fusions were initiated, followed by tactical evacuation to Role proposed to prevent death, resuscitation in the setting of trau-
2 and 4-hour observation. Results: All animals developed sus- matic cardiac arrest (TCA) after combat injury remains an al-
tained asystole. Chest compressions supported effective but most universally fatal endeavor, with no optimal intervention
gradually deteriorating blood circulation. Two animals un- having been identified to support salvage of these casualties.
derwent successful E-CPR, with restoration of perfusion pres-
sure to 80mmHg (70–90mmHg) 25 and 23 minutes after the An 11-year database analysis of the UK Joint Theatre Trauma
induction of CA. After transportation to Role 2, one animal Registry previously reported on 424 casualties (4.6% of all
developed abdominal compartment syndrome as a result of registered patients) with CA caused mostly by explosive or
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extensive (9L) fluid replacement. The other animal received gunshot injuries. The authors found that 10.6% of casualties
a lower volume of crystalloids (4L), and no complications who arrested after arrival at the Role 3 medical treatment fa-
occurred. In the third animal, multiple attempts to cannulate cility (MTF) survived to discharge, with most of them (80%)
arteries were unsuccessful because of spasm and hypotension. presenting with injuries consistent with major hemorrhage.
Open aortic cannulation enabled the circuit to commence. No Resuscitative thoracotomy was the only performed life-saving
return of spontaneous circulation was ultimately achieved in surgical procedure attempted in this series, but this heroic in-
either of the remaining animals. Conclusion: Our study demon- tervention did not affect survival.
strates both the potential feasibility of battlefield E-CPR and
the evolving capability in the care of severey injured combat As combat medical providers continue to strive to improve
casualties. outcomes for critically unstable casualties and TCA victims,
newer life-saving techniques have been proposed to expediently
restore systemic and central circulation. These novel interven-
Keywords: combat trauma; extracorporeal membrane oxy- tions include resuscitative endovascular balloon occlusion of the
genation; endovascular; battlefield; cardiac arrest; cardio- aorta (REBOA), selective aortic arch perfusion, emergency
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pulmonary resuscitation preservation and resuscitation, and extracorporeal membrane
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oxygenation (ECMO). 10,11 Many of these techniques are now
extensively used in select civilian trauma centers and have also
been investigated for field implementation. 12,13
*Correspondence to vreva@mail.ru
1 LTC Reva serves in the Russian Army, MC, Department of War Surgery, Kirov Military Medical Academy, and Department of Polytrauma,
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Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russian Federation. LT Pochtarnik serves in the Russian Army, MC,
Department of War Surgery, Kirov Military Medical Academy. Dr Shelukhin is affiliated with the Department of Anesthesiology and Reanima-
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tology, Nikiforov Russian Center of Emergency and Radiation Medicine of EMERCOM, Saint Petersburg. Dr Skvortzov is affiliated with the
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Department of Organ Donation and Transplantation, Dzhanelidze Research Institute of Emergency Medicine, and Pavlov First Saint Petersburg
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State Medical University, Saint Petersburg. CPT Semenov serves in the Russian Army, MC, Department of War Surgery, Kirov Military Medical
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Academy, Saint Petersburg. LTC Emelyanov serves in the Russian Army, MC, Department of Anesthesiology and Reanimatology, Kirov Military
Medical Academy. CPT Nosov serves in the Russian Army, MC, Scientific Laboratory of War Surgery, Kirov Military Medical Academy. MAJ
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Demchenko serves in the Russian Army, MC, Scientific Laboratory of War Surgery, Kirov Military Medical Academy. Dr Reznik is affiliated
with the Department of Organ Donation and Transplantation, Dzhanelidze Research Institute of Emergency Medicine, and Pavlov First Saint
Petersburg State Medical University. COL Samokhvalov served in the Russian Army, MC (Ret.), Department of War Surgery, Kirov Military
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Medical Academy. Col DuBose serves in the USAF, MC, R Adams Cowley Shock Trauma Center, University of Maryland Medical System,
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Baltimore, MD.
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