The Use Extracorporeal Membrane Oxygenation Therapy in a Severe Blunt Chest Trauma with a Main Tracheal Injury

Case Report

Austin Crit Care J. 2021; 8(1): 1033.

The Use Extracorporeal Membrane Oxygenation Therapy in a Severe Blunt Chest Trauma with a Main Tracheal Injury

Zhang J¹, Han H¹, Liu H¹, Li Y¹, Wu M² and Chen X¹*

1Department of Critical Care Medicine, Qilu Hospital of Shandong University, China

2Department of Thoracic Surgery, Qilu Hospital of Shandong University, China

*Corresponding author: Xiaomei Chen, Department of Critical Care Medicine, Qilu Hospital of Shandong University, Wenhuaxi Road 107, Jinan 250012, China

Received: February 16, 2021; Accepted: February 24, 2021; Published: March 03, 2021


Major tracheobronchial trauma by blunt chest trauma is high mortality rates worldwide. The use conventional mechanical ventilation in a tension pneumothorax patient by major tracheobronchial trauma has been ineffective with barotrauma. However, the application of Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) in trauma patients has been controversial, but VV-ECMO plays a crucial role when conventional management has failed. VV-ECMO provides adequate tissue oxygenation and an opportunity for recovery. Neither ECMO-associated bleeding nor clotting of the extracorporeal circuit is an upmost for trauma patients. We report a case of previously healthy 16-year-old man with left main bronchial rupture after vehicular accident, who had progressive dyspnea and left tension pneumothorax. After the chest tube drainage, double-lumen endotracheal intubation and mechanical ventilation initiation, severe respiratory distress kept on deterioration. On VV-ECMO transfer to our hospital, we performed emergency thoracotomy and identified the rupture of the left main bronchus. After operation, the patient’s condition improved. VV-ECMO and mechanical ventilation were stopped on days 8 and 9, respectively. He was discharged without complications from the ICU on day 20.

Keywords: Veno-venous extracorporeal membrane oxygenation; Blunt trauma; Major tracheobronchial rupture


Major Tracheobronchial Trauma (MTT) by blunt chest trauma is extremely rare (1-3 %) and high mortality rates worldwide, especially in young adults. A rapid increase in tracheobronchial pressure can lead to blowout perforation of the trachea, which can lead asphyxia. Most of the MTT patients die before arriving at the hospital. It remains a challenge for trauma critical care. The early diagnosis of the highly lethal injury is crucial for survival [1]. Generally, initial management includes airway established, decompression of pneumothorax, and hemorrhage control. Additionally, support with Extracorporeal Membrane Oxygenation (ECMO) as a temporary rescue modality offers potential benefit survive in trauma patients [2-4]. ECMO is able to provide respiratory and cardiovascular support for patients. However, systemic heparinization is a key issue for ECMO as it can induce intracranial and surgical site bleeding with heparinization. We present a successful case of a teenager with left bronchi rupture due to severe crush injury, who received ECMO as supportive therapy on perioperative period, and discuss the heparin-free ECMO application.

Case Presentation

A 16-year-old male suffered a blunt thoracic trauma after being crashed into a tree while riding his electric bicycle. He was rushed to local emergency department. Physical examination revealed a blood pressure of 110/60 mmHg with a heart rate of 128 beats/min, a spontaneous respiration rate of 30 breaths/min and a pulse oxygen saturation (SpO2) of 80%. Breathing was inaudible by auscultation in the left lung. Whole body Computed Tomography (CT) was performed without showing any intracranial hemorrhages or definitive abdominal organ injuries. The chest CT scan showed leftside tension pneumothorax. Prompt left closed thoracic drainage was performed with a rush of air. Simultaneously, fluid was infused and immobilization of the chest wall was done. Despite above done, his SpO2 level decreased to 73%. Therefore, single-lumen endotracheal intubation followed by double-lumen endotracheal intubation was inserted and Mechanical Ventilation (MV) was started. However, persistent large-volume air leaks and poor tidal volumes still existed. Due to the technical restriction for further surgery treatment in the local hospital, our hospital ECMO team were sent to perform Veno- Venous (VV) ECMO. Catheters were inserted into the left jugular vein (17-Fr cannula for inflow, the tip nearly reached right atrium) and right femoral vein (21-Fr cannula for outflow, the tip located at inferior vena cava). After we established VV-ECMO with heparin (Maquet, ROTAFLOW Console, Germany) at 4000 rpm on pump flow, 5L/min on gas flow and FdO2 on 0.8, the patient’s SpO2 quickly rising at 100% and his respiratory distress was alleviated significantly, allowing about 146 km transport to our hospital. The injury severity score was 17 and the probability of survival was 0.63.

Flexible bronchoscopy and second CT (Figure 1) were performed immediately in our hospital, but did not enable us to accurately visualize the tracheobronchial lesions. After multidisciplinary discussion and agreement, patient was taken to the operating room for thoracotomy as well under general anesthesia and ECMO. Rupture length of 3.5 cm and two third of the circumference in left side of main bronchus were detected. Additionally, multiple longitudinal diffuse fissures with inflammatory edema on the 6cm length between left main bronchus to segment of bronchi were also identified (Figure 2). Considering several failure attempts to repair the rupture and probably inevitable bronchopleural fistula, the decision was to perform the whole left pneumonectomy. The operating time was lasting for 3 hours with a blood loss volume of 100 ml. After change to a single lumen tube, the patient was readmitted to the ICU. When the initiation of ECMO with standard heparin, heparin was micro-pump injected (125-750 u/hour), and Activated Clotting Time (ACT) was monitored in every 2 hours. ACT was remained between 160s to 180s. Meanwhile, arterial and venous blood gas were tested every 6 hours. Starting at 6 hours before the surgery, heparin was stopped on ECMO to ensure less bleeding until the end of the surgery. Heparin-free ECMO was remained 7.5 hours without increasing the pump flow.

Citation: Zhang J, Han H, Liu H, Li Y, Wu M and Chen X. The Use Extracorporeal Membrane Oxygenation Therapy in a Severe Blunt Chest Trauma with a Main Tracheal Injury. Austin Crit Care J. 2021; 8(1): 1033.