(1744) Give the Lungs a Breather: ECMO in the Critical Polytrauma Patient

Introduction: The use of extracorporeal membrane oxygenation (ECMO) is well described in cases of severe pulmonary dysfunction and cardiopulmonary failure. Its use in the trauma patient population and its effect on mortality and morbidity is far less documented, particularly in the case of significant Acute Respiratory Distress Syndrome (ARDS) as a result of severe polytrauma.

Description: A 30 year old male with history of prior hospitalizations for asthma exacerbations requiring mechanical ventilation presented after a motor vehicle collision. The patient was found near his vehicle in extremis but was successfully revived after a round of cardiopulmonary resuscitation. Upon arrival, he was noted to be hypoxic and was intubated for airway protection. Imaging demonstrated bilateral pneumothoraces with rightward mediastinal shift prompting bilateral chest tube placement. Additional injuries included bilateral acute displaced rib fractures as well as a right femoral shaft fracture. With progression of bilateral pulmonary contusions, the patient was managed with lung-protective ventilation, but he continued to decompensate with elevated plateau and peak airway pressures. Given these findings and a known history of severe asthma, he was treated with nebulized albuterol, racemic epinephrine, intravenous magnesium and steroids and ultimately required vasopressor support, ketamine infusion and multiple bronchoscopies for presumed status asthmaticus. Despite these interventions, the patient had two subsequent episodes of cardiac arrest with immediate return of spontaneous circulation. While the patient initially appeared to clinically improve, he again decompensated despite escalating all supportive measures. After a multidisciplinary discussion between trauma, pulmonology, and cardiothoracic surgery, he was placed on veno-venous EMCO. He clinically was able to make a complete recovery with discharge to rehabilitation center within one month of admission.

Discussion: ARDS is a demanding physiology, particularly in the setting of polytrauma where rib fractures and pulmonary contusions make management challenging. Our case describes the use of ECMO in a polytrauma patient with status asthmaticus where several factors including length of stay and overall mortality and morbidity may have benefited from its use.