The Danish Invasion
The Danish National
Hypothermia Team
Use of portable ECMO-device in hypothermic patients
and alternative applications
C. Simonsen1,, B. Kjærgaard1,2
Danish Armed Forces
Health Services
1. Dept. of Cardiothoracic surgery, Center for Cardiovascular Research, Aalborg University Hospital. Royal
Danish Armed Forces Health Service, RDAF SAR SQN 722
2. Biomedical Research Laboratory, Aalborg University Hospital.
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Disclamers
The authors of this presentation
has no commercial or financial
interest in the matters discussed.
Opinions expressed in this
presentation are personal opinions
of the authors and do not
necessarily reflect the policy of the
Royal Danish Air Force.
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Overview
• The team – organisation
• Hypothermia – The Danish approach
• Case with ECMO treated severe
hypothermia
• Case with ECMO used in a trauma
setting
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Location
1 hour
xxx
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The Team
• 1 Thoracic Surgeon
• 1 Perfusionist
• Team is alerted by Request
from other hospital or AMK
(Acute Medical
Coordination).
• If needed AMK Request
Helicoptor assistance via
Joint Rescue Coordination
Centre (JRCC)
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ECMO
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How did it start?
1999: Research started for the
implementation of ECMO
300-400 kg
40 kg
First patient treated in 2004
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Hypothermia:
The Danish approach
Focuses on the clinical condition and not
solely on the core temperature
1. Mild hypothermic patient: Below 35°C.
Awake (Glasgow Coma Scale > 8).
2. Moderate hypothermic patient: Below 32°C
and unconscious.
3. Severe Hypothermic patient: Below 32°C,
unconscious and abscent respiration/
circulation.
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Treatment: Strategies
1.
Mild hypothermic patient: Below 35°C. Awake (Glasgow Coma
Scale > 8).
Treatment: ABC, External warming
2.
Moderate hypothermic patient: Below 32°C and Unconscious.
Treatment: ABC, rewarmed by pleural lavage.
3.
Severe Hypothermic patient: Below 32°C, unconscious and
abscent respiration/circulation.
Treatment: ABC including CPR. Rewarming can
be established by extra corporeal circulation
Unless patient is dead!
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Oxygen need
37 ºC = 100 %
20 ºC = 20 %
Some die of
hypothermia
Some survive
because of
hypothermia
Cooling to 20 ºC and 2 hours without
circulation: Rewarming…..
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Treatment: When to stop
As a guideline the following criteria are used
when deciding to terminate resuscitation:
•
Asystole and P-potassium > 10 mmol/l
•
Asystole and temperature > 32 oC
•
Cadaverositas – (NOT rigor mortis/livor
mortis)
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The Præstø Case
Water temperature: 2oC
Air temperature: 4 oC
Wind: 7-13 m/s (14-25 knots)
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The Præstø Case
February 2011: 13 teenagers and 2 teachers in
a little boat
14 were rescued
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The Præstø Case
7 of the rescued teenagers suffered from
cardiac arrest.
• Dilated unresponsive pupils
• The core temperature 15,5-20,2 °C
• pH-level between 6.43–6.94
• ECMO established 178–241 min after the
accident.
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The Præstø Case
6 was transferred to Copenhagen
University Hospital Rigshospitalet
and treated with ECMO
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The Præstø Case
Andreas
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The Præstø Case
4 months later
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The Præstø Case
Boring but important Table
Patient
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M/F
Age
EMS
Temp.
pH
CC
GCS
ECG
ECMO
1
M
15
121
16,0
6,59
57
3
VF
178
2
M
16
121
20,2
6,62
56
3
VF
179
3
M
15
168
18,4
6,43
65
3
AS
233
4
F
16
153
15,5
6,61
88
3
PEA
241
5
F
15
168
19,4
6,90
58
3
VF
226
6
M
16
108
17,5
6,52
120
3
VF
228
7
M
17
108
20,0
6,94
?
3
AS
233
8
M
16
106
34,2
ND
ND
15
SR
ND
9
F
16
108
23,0
7,00
2
3
PVC
ND
10
F
16
91
36,4
ND
ND
15
SR
ND
11
F
16
104
27,5
7,27
ND
12
SR
ND
12
F
17
96
37,5
ND
ND
15
SR
ND
13
F
16
113
35,9
7,33
ND
15
SR
ND
14
F
33
96
28,0
ND
ND
12
SR
ND
EMS= time for first contact with emergency medical services, CC=duration of chectcompression
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The Præstø Case
Outcome
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Tractor incident
18. september 2014
67 years old
farmer run over
by tractor.
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Tractor incident
•
•
•
•
•
•
•
Multiple rib fractures
Pneumothorax
Hemothorax
Lung contusion
Crushed pelvis
Intra abdominal injuries
GCS 3
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Tractor incident
Needed emergency surgery
• Insufficient oxygenation
• Bleeding
• Cold
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Tractor incident
Veno-venous ECMO
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Tractor incident
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Tractor incident
Discharged after 4 months
• Ileostomy
• Cerebral- and kidney function was intact
• No major disabilities
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ECMO: Alternative applications
Buy time for
• Diagnostics (e.g. CT-scan, CAG)
• Intervention (PCI, surgery)
• Recovery
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Hypothermia Team Activities 2004-2015
270 cases
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Perspective
Long distance evacuation (2006)
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Perspective
Potential for further advanced methods
• Novalung (pumpless ECMO)
• Impella
• Even smaller ECMO-machine (standard
equipment?)
Prototype: 4 kg
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Conclusion
As with the hypothermic patient, huge
benefits can be achieved when bringing
portable ECMO-device and capable
personnel to other types of critical
illness/traumas e.g.
•
•
•
•
•
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Asthma attacks
Heart attacks
Pulmonary embolism
Severe pneumonias
Blast lungs
Long distance evacuation while patient
is on ECMO is possible.
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Thank You!
Denmark offers excellent conditions for further research in
MEDEVAC using cardio-pulmonary assist
• Experience with porcine models
• Tradition for civil/military cooperation
• Legislation regarding research animals
International cooperation within this field of research is
welcomed!
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