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primarily evaluating the field logistics and feasibility of the Conflict of Interest
procedure rather than state-of-the-art care. Second, this study All products and instruments described and discussed in this
lacks stringent monitoring and laboratory-guided resusci- manuscript were either purchased by authors or provided by
tation capabilities. Although during closed CPR the utilized their units, except the portable perfusion device that was sup-
MAP monitoring demonstrated an adequate initial perfusion, plied for free by the manufacturer.
continuous monitoring during transportation could not be
used to exclude undocumented episodes of hypoperfusion. Author Contributions
Hemodilution and acidosis were clearly demonstrated by VAR, DAS, ONR, IMS, and JJD conceived the study design.
point-of-care testing results but are likely largely attributable VAR, AAP, DAS, EAS, AMN, and KND performed the ex-
to the more liberal use of crystalloids than would have oc- periments. VAR, AES, and AAE collected and analyzed the
curred in actual contemporary practice. It is likely that modern data. VAR, DAS, AES, and ONR interpreted the data. VAR
whole blood resuscitation strategies as outlined in the ARC and JJD wrote the first draft. IMS and ONR critically revised
protocols would result in more consistent laboratory results the manuscript, and all authors read and approved the final
2
in future study animals. The present study did, however, use manuscript.
the implementation of CPR in accordance with current ba-
sic and advanced life support recommendations. This resulted
in a temporary elevation of MAP, which permitted effective References
1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
transportation to a location where more advanced resusciati- (2001–2011): implications for the future of combat casualty care.
eve and hemorrhage control techniques might be available. J Trauma Acute Care Surg. 2012;73:S431–S437.
2. Butler FK Jr, Holcomb JB, Shackelford S, et al. Advanced resus-
Despite these limitations, the present work is the first to demon- citative care in Tactical Combat Casualty Care: TCCC guidelines
strate the potential feasibility of V-A ECMO use during far- change 18-01:14 October 2018. J Spec Oper Med. 2018;18:
37–55.
forward resuscitative care to support casualties with TCA who 3. Penn-Barwell JG, Roberts SAG, Midwinter MJ, Bishop JRB. Im-
would otherwise be considered unsalvageable. The potential role proved survival in UK combat casualties from Iraq and Afghani-
for battlefield E-CPR, however, requires additional examination. stan: 2003–2012. J Trauma Acute Care Surg. 2015;78:1014–1020.
It might warrant consideration at Role 2 facilities with more ro- 4. Barnard EBG, Hunt PAF, Lewis PEH, Smith JE. The outcome of
bust surgical capability for casualties admitted in extremis with patients in traumatic cardiac arrest presenting to deployed mili-
impending CA but not frank arrest. In this fashion, E-CPR might tary medical treatment facilities: data from the UK Joint Theatre
serve to expediently support (rather than substitute) a casualty’s Trauma Registry. J R Army Med Corps. 2018;164:150–154.
circulation. However, as required technology continues to evolve 5. Morrison JJ, Galgon RE, Jansen JO, et al. A systematic review
of the use of resuscitative endovascular balloon occlusion of the
(an ECMO machine and kit can be carried in a rucksack now), aorta in the management of hemorrhagic shock. J Trauma Acute
and as concurrent improvements in skills training and rapid ca- Care Surg. 2016;80:324–334.
sualty transport develop, E-CPR may soon become an option in 6. Gamberini E, Coccolini F, Tamagnini B, et al. Resuscitative en-
the armamentarium of specific care providers even closer to the dovascular balloon occlusion of the aorta in trauma: a systematic
point of injury. The effective implementation of early E-CPR in review of the literature. World J Emerg Surg. 2017;12:42. doi:
10.1186/s13017-017-0153-2
the forward military setting seems to be logistically, mentally, 7. Manning JE, Murphy CA, Hertz CM, et al. Selective aortic arch
and technically challenging, but in the future, it may become a perfusion during cardiac arrest: a new resuscitation technique.
bridge from “killed in action” to “returned to duty.” Ann Emerg Med. 1992;21:1058–1065.
8. Barnard EBG, Manning JE, Smith JE, et al. A comparison of selec-
tive aortic arch perfusion and resuscitative endovascular balloon
Conclusion occlusion of the aorta for the management of hemorrhage-
induced traumatic cardiac arrest: a translational model in large
The present study in a porcine model demonstrates the fea- swine. PLoS Med. 2017;14:e1002349. doi: 10.1371/journal.
sibility of V-A ECMO for use during TCCC and forward pmed.1002349
resuscitative care at Role 1 or 2. CPR (closed and then ex- 9. Kutcher ME, Forsythe RM, Tisherman SA. Emergency preserva-
tracorporeal) may play a potential role in improving survival tion and resuscitation for cardiac arrest from trauma. Int J Surg
in future warfare. Further investigations are warranted to de- Lond Engl. 2016;33:209–212.
termine indications, optimal training, equipment, and utiliza- 10. Arlt M, Philipp A, Voelkel S, et al. Extracorporeal membrane ox-
tion protocols required to facilitate the effective integration of ygenation in severe trauma patients with bleeding shock. Resusci-
tation. 2010;81:804–809.
ECMO into military forward-care capabilities. 11. True NA, Siler S, Manning JE. Endovascular resuscitation tech-
niques for severe hemorrhagic shock and traumatic arrest in the
Financial Disclosure presurgical setting. J Spec Oper Med. 2013;13:33–37.
AES is a founder and director of TransBiotech, Ltd. (Russian 12. Reva VA, Hörer TM, Makhnovskiy AI, et al. Field and en route
Federation), the resident of Skolkovo Foundation. The other resuscitative endovascular occlusion of the aorta: a feasible mili-
authors have indicated they have no financial relationships rel- tary reality? J Trauma Acute Care Surg. 2017;83:S170–S176.
evant to this article to disclose. 13. Ross EM, Redman TT. Feasibility and proposed training path-
way for austere application of resuscitative balloon occlusion of
the aorta. J Spec Oper Med. 2018;18:37–43.
Funding 14. Bonacchi M, Spina R, Torracchi L, et al. Extracorporeal life
This study is supported by a grant from the Russian Science support in patients with severe trauma: an advanced treatment
Foundation #17-73-20318. strategy for refractory clinical settings. J Thorac Cardiovasc Surg.
2013;145:1617–1626.
15. Tonna JE, Johnson NJ, Greenwood J, et al. Practice characteris-
Disclaimer tics of Emergency Department extracorporeal cardiopulmonary
The views expressed are solely those of the authors and do not resuscitation (eCPR) programs in the United States: the current
reflect the official policy or position of the Ministry of Defense state of the art of Emergency Department extracorporeal mem-
of the Russian Federation or the U.S. Air Force. brane oxygenation (ED ECMO). Resuscitation. 2016;107:38–46.

82 | JSOM Volume 20, Edition 4 / Winter 2020