(1564) Extracorporeal Membrane Oxygenation for Severe Pulmonary Contusions With Active Hemoptysis

Introduction: Mechanical ventilation for severe lung contusions has often difficulties because oxygenation cannot be maintained due to destruction of lung parenchyma and pulmonary hemorrhage, and ventilator-induced lung injury can exacerbate lung trauma during mechanical ventilation.

Description: A 20-year-old man was transferred to the hospital after a fall-down trauma. A whole body computed tomography scan revealed pulmonary contusions with extravasations from left pulmonary arteries, multiple rib fractures, thoraco-lumbar burst fractures, and left tibiofibular open fractures. Resuscitation with an endotracheal intubation, massive blood transfusions and transcatheter arterial embolization (TAE) to left pulmonary arteries were immediately performed. During TAE, differential lung ventilation was initiated because of active pulmonary bleeding. After resuscitation, he was admitted to the intensive care unit. On admission, his arterial oxygen partial pressure to fractional inspired oxygen was 100 and deteriorated to 60 after several hours. Veno-venous extracorporeal membrane oxygenation (ECMO) without anticoagulation was introduced to correct poor oxygenation and to perform protective lung ventilation. During ECMO, left lung ventilation was done with continuous positive airway pressure (CPAP) of 25 cmH2O to control bleeding. Three days after the admission, differential lung ventilation was ended after hemostasis was confirmed by fibrotic bronchoscopy. The patient was liberated from ECMO and mechanical ventilation five and fifteen days after the admission.

Discussion: Severe pulmonary contusions may require invasive mechanical ventilation because of severely impaired gas exchange capacity. However, mechanical ventilation can exacerbate lung contusions giving shear stress to damaged tissues. The severer the initial lung damage is, the harder it is to balance lung protective ventilation and maintenance of gas exchange. Rescue therapy with ECMO enables the ultraprotective lung ventilation such as CPAP, which could minimize the shear stress and be effective to suppress alveolar hemorrhage. In addition, anticoagulation strategies should be carefully chosen considering patients’ coagulation-fibrinolysis state during ECMO on traumatic patients.