From the annual meeting of the Eastern Association for the Surgery of Trauma
Major advances in medicine are rarely without controversy, but when you add in pulseless patients being figuratively put on ice without enough time for informed consent, it goes without saying that the launch of the phase II Emergency Resuscitation and Preservation for Cardiac Arrest from Trauma (EPR-CAT) trial will ignite debate in the coming months. (See my recent article for more details on the study.)
Induced hypothermia is routinely used in pediatric and cardiac populations, but never in exsanguinating trauma patients with blunt or penetrating wounds – the cohort earmarked for the multicenter trial. As a result, the FDA is requiring that investigators across the country state their case to the community in the coming months for what was once known as suspended animation, said principal investigator Dr. Samuel Tisherman, associate director of the Safar Center for Resuscitation Research at the University of Pittsburgh.
Their primary target is those most at risk of lethal gunshot or stab wounds – think Hells Angels and gangbangers. The mind boggles at the permutations, but young adults stand to benefit the most from the use of EPR, which buys surgeons valuable time to access and potentially repair complex traumatic wounds.
Convincing families that EPR is the best option and that current therapy offers virtually no hope for exsanguinating trauma patients in cardiac arrest is yet another matter. Americans have short memories and forget that not that long ago the idea of flying organs across the country in a Lear jet was considered ghoulish, as was Grandpa’s pacemaker and the veteran’s artificial limb. (The U.S. Department of Defense is providing funding for the EPR study.)
And what if once inside, the surgeon finds that the wounds are not repairable? Did I mention that EPR is a wonderful means to preserve organs for transplant? It is; meaning some families will undoubtedly question whether the surgeon’s loyalties were to their loved one on the table or the seven recipients of his or her organs. Organ donation programs are set up to avoid any divided loyalties among treating physicians, but trying to convince families of this will be problematic when a young life is lost.
And, finally, how will families react if physiologic and neurologic outcomes of EPR are less than desirable? A previous study showed that swine with uncontrolled lethal hemorrhage display normal learning and memory after induced hypothermic arrest, meaning they could be trained to retrieve food from color-coded boxes. Still, animal rights activists as far away as Australia blasted the investigators for conducting the research, admitted a somewhat gun-shy Dr. Tisherman.
The EPR-CAT investigators face a plethora of ethical and medical challenges in their attempts to push the boundaries of science, but how else can we move forward?
– Patrice Wendling (on Twitter @pwendl)