Emergency preservation and resuscitation, a technique that induces profound hypothermia to delay cellular injury, may extend survival in patients with noncompressible torso hemorrhage and traumatic cardiac arrest, according to a narrative review.
Noncompressible torso hemorrhage remains the leading cause of preventable death in combat trauma, accounting for 91% of potentially survivable battlefield deaths, with 67% attributed to this injury pattern. These injuries can lead to rapid cardiac arrest when surgical intervention is delayed, particularly in environments with prolonged evacuation times.
Methods and Evidence Base
This narrative review examined the development of emergency preservation and resuscitation (EPR), including preclinical models, early clinical investigation, and emerging technologies aimed at extending survival in exsanguination cardiac arrest.
EPR involves rapid infusion of ice-cold fluids to reduce core and brain temperatures to approximately 10 °C, inducing a hypometabolic state that reduces oxygen demand and delays ischemic injury. This approach may allow a window of up to 60 minutes for hemorrhage control and damage control surgery before controlled reperfusion and gradual rewarming.
Clinical feasibility has been evaluated in the Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma trial, which enrolled patients aged 18 to 65 years with penetrating trauma who lost vital signs within 5 minutes of arrival. The primary endpoint was survival to hospital discharge without significant neurologic sequelae.
Key Findings
Preclinical studies suggested that EPR can extend tolerance to circulatory arrest while preserving neurologic function. In a porcine model of complex abdominal and vascular injury, EPR protocols resulted in more than 75% survival at 6 weeks with intact neurologic function.
Additional studies showed that hypothermic circulatory arrest lasting up to 60 minutes preserved learning and memory, and optimized protocols were associated with survival after up to 120 minutes of arrest in experimental models. Outcomes were dependent on rapid cooling and controlled rewarming, with delays in cooling associated with decreased survival.
The review also described adjunctive technologies, including extracorporeal life support systems, controlled reperfusion platforms, and pharmacologic agents designed to support microcirculation and reduce ischemia-reperfusion injury.
Limitations
Most supporting data remain preclinical, and implementation in clinical practice is limited by logistical complexity, need for specialized personnel, and challenges in deploying EPR outside advanced trauma centers. Additional concerns include hypothermia-associated coagulopathy, anticoagulation requirements during extracorporeal circulation, and risk of reperfusion injury.
Conclusion
EPR represents a potential strategy to extend survival in traumatic cardiac arrest by delaying cellular injury until definitive care is available. As Mason H Remondelli, of Uniformed Services University of the Health Sciences, Bethesda, Maryland, and colleagues wrote, EPR “may provide a critical capability to reduce mortality from NCTH and revolutionize combat trauma management in [large-scale combat operations] scenarios.”
Disclosures: The researchers reported no competing interests.
Source: Trauma Surgery & Acute Care Open
