Calm before the storm - austere environments - challenging indications (trauma)

Extracorporeal membrane oxygenation (ECMO) is increasingly used as an adjunct in the management of critically injured trauma patients requiring operative intervention. Although trauma represents a small proportion of overall ECMO use, its application has expanded due to advances in circuit technology, cannulation strategies, and anticoagulation practices. This review examines the role of ECMO in stabilizing operative trauma patients across preoperative, intraoperative, and postoperative phases. Preoperatively, ECMO is most commonly indicated for refractory hypoxemia or severe acidosis resulting from thoracic or airway injury, aspiration, transfusion-related acute lung injury, or acute respiratory distress syndrome. Early cannulation can restore gas exchange, improve hemodynamic stability, reduce ventilator-induced lung injury, and facilitate safe transport to the operating room during damage control resuscitation. Emerging evidence also supports selective use of ECMO in patients with traumatic brain injury requiring urgent neurosurgical intervention. Intraoperatively, ECMO has been used during high-risk damage control procedures, including trauma pneumonectomy, retrohepatic inferior vena cava injury, and operations complicated by hemorrhage, hypothermia, and acidosis. Veno-venous ECMO may improve oxygenation and reduce right ventricular strain, while veno-arterial ECMO may be appropriate in select cases of traumatic cardiogenic shock. Postoperatively, ECMO is most often employed for delayed respiratory failure due to acute respiratory distress syndrome, transfusion-related lung injury, or bronchopleural fistula, allowing lung-protective ventilation and recovery. Although evidence supporting ECMO for traumatic respiratory failure continues to grow, data for other perioperative indications remain limited. Prospective multicenter studies are needed to refine patient selection, timing, and outcomes in operative trauma populations.