Successful management of traumatic lung injury using Veno-venous ECMO in a young RTA patient

S. Pavithra1*, Mohammed Faizal2

1OT Staff Nurse, Kauvery Hospital , Tirunelveli, Tamil Nadu

2Anesthesia Technician, Kauvery Hospital, Tirunelveli, Tamil Nadu

*Correspondence

Case Presentation

Mr. XY is a 49-year-old male patient currently admitted to the Neuro ICU. Alleged H/O RTA (Road Traffic Accident) – 2-wheeler vs 4-wheeler on 17/02/2026 around 7:30 PM. Patients were initially treated at VMCH and later referred here for further management. Upon admission, the patient was intubated

GCS: 8/15

LOC: Present

Injuries noted

  • Head injury
  • Multiple rib fractures – Right side
  • Right pneumothorax
  • Right Femur Fracture
  • Multiple lacerations over face

On Examination

CVSS1, S2 +
RSRight AE ↓, Left AE +, Bilateral crept +
SpO₂94% on MV support
CNSPatient conscious, bilateral pupils 2 mm reacting to light.

Initial Treatment Given

  • Antifibrinolytics
  • Antibiotics
  • Antiepileptics
  • Antiemetics
  • Injection Perfalgan + Midazolam
  • Other supportive drugs

Investigations: Blood investigations done, reports enclosed.

CT Report: Cutaneous laceration with air pockets in right frontal region.

HRCT Chest Report

  • Fracture of 2nd, 5th, 6th ribs
  • Undisplaced fracture of 3rd, 5th ribs
  • Other imaging reports enclosed.

Specialty Reviews

  • Neurosurgeon reviewed the patient.
  • Opinions obtained from Ortho, Cardiothoracic surgeon,
  • Pulmonology, Gastro, General surgeon.

ETU/ER Review: Advised Right ICD (Intercostal Drainage) insertion for pneumothorax.

Chief Complaints

The patient was admitted following an alleged road traffic accident involving a collision between a two-wheeler and a four-wheeler. The incident occurred at 7:30 PM on February 17, 2026, at the Ayyur road junction, resulting in a documented loss of consciousness.

Details of Present Illness

  • Multiple rib fractures on right side
  • Right pneumothorax
  • Right Femur Fracture
  • Patients got admitted in ICCU/ICU for further management

Associated Injuries

  • Head injury
  • Multiple lacerations over face

Past History

  • No H/O fever, cold, seizures, vomiting
  • No known diabetes or hypertension
  • No alcohol / non-smoker
  • History of Past Illness: Nil comorbid illness

Examination

CVSS1, S2 present
RSRight AE ↓, Left AE +, Bilateral crepitations +

Vitals

SpO₂100% with MV support
BP130/70 mmHg
HR121/min
RR16/min
TempNormal
CNS Unconscious
Pupils Bilateral 3 mm reacting

Plan

ETT with mechanical ventilation (ETT + MV support) Provisional Diagnosis RTA – Poly trauma Right pneumothorax Multiple rib fractures (Right side) Focus ICD (Intercostal Drain) inserted Collection about 1.3 cm Lung expansion about 3 cm

  • Right side pneumothorax
  • Right pleural cavity filled with air
  • CT – Trauma major package
  • X-ray Chest – AP view
  • X-ray Right Femur
  • X-ray Right Shoulder
  • X-ray Right Leg

Proposed Care Plan

  • Intubation with MV support
  • ICD insertion
  • IV fluids
  • NS infusions

Medications

  • Xone 1 g IV BD
  • Pan 40 mg IV BD
  • Emeset 4 mg IV BD
  • Tranexamic acid 1 g IV stat

Indication for ECMO

  • Severe hypoxemia does not respond to mechanical ventilation
  • Hemodynamic instability
  • ARDS

ECMO team

Date    : 22–23 Feb 2026

Team   : Dr. Arun Singh / Dr. A.P.S. Kannan / Dr. Selvi

Patient Vitals

  • BP: 100/90 mmHg (on Noradrenaline infusion)
  • PR: 86/min
  • SpO₂; 83%
  • P/F ratio: <100 × >12 hrs
  • Indicates severe hypoxemia
  • Clinical Decision
  • Attenders informed about need for ECMO
  • Prone positioning not possible

Risks explained

  • Increased bleeding
  • Multiple transfusions
  • Prolonged ICU stay
  • Decision: Proceeded for VV-ECMO

ECHO Findings

  • LV EF: 50%
  • RA/RV: Normal
  • TAPSE: 1.8 cm
  • IVC: 1.2 cm, collapsing
  • Suggests preserved cardiac function → suitable for VV ECMO
  • Lung Ultrasound (USG)
  • B/L B lines present
  • Left > Right
  • Indicates severe lung involvement (likely ARDS)
  • ECMO Procedure Notes (23-02-2026 | 1:00 PM)

Preparation

ECMO procedure

  • Patient evaluated and decision taken for ECMO cannulation under sterile precautions.
  • Patients sedated and intubated.
  • Monitoring lines secured.
  • Cannulation done via femoral vein / internal jugular vein
  • ECMO circuit connected.
  • Adequate blood flow established.
  • Oxygenation improved after initiation.

Medications

  • Heparin infusion for anticoagulation
  • Sedation and analgesia
  • Antibiotics
  • Inotropic support (if required)
  • Monitoring Plan
  • Continuous ECG monitoring
  • ABG monitoring
  • ACT / coagulation profile
  • ECMO circuit monitoring
  • Intake and output charting

Plan

  • Continue ECMO support
  • Daily assessment for weaning
  • Monitor for complication
  • Whole body draped
  • TEE placed

Cannulation Details

Guidewire Placement (Right Femoral Vein)

  • Micro puncture access
  • 7 Fr sheath placed
  • 150 cm guidewire placed
  • Confirmed under TEE guidance

Serial Dilatation

Femoral vein: 12 Fr → 24 Fr → 26 Fr

Cannula Insertion

Femoral cannula: Mac Vic Multistage Venous Cannula 26 Fr inserted under TEE

Return cannula (IJV) inserted

Image Source: Tarig Eltoum Fadelelmoula, researchgate, May 2020

Right IJV

  • Micro puncture needle used
  • 7 Fr sheath placed

IJV: MAQUET 17 FR ARTERIAL CANNULA

  • Fixed at 15 cm
  • Anticoagulation
  • Heparin 5000 IU IV given
  • ACT monitored

ECMO Initiation

  • Flow established
  • RPM gradually increased
  • No chattering

ECMO Settings

  • Mode: VV ECMO
  • Blood flow: 4.2 L/min ~3500 RPM
  • Sweep gas flow: 4 L/min
  • FiO₂: 100 %
  • Patient Status Post ECMO
  • Hemodynamically stable
  • Oxygen saturation improved
  • Ventilator support continued
  • Urine output monitored

Chest X-ray (AP View) – Interpretation

Technical

  • View : AP (Bedside)
  • Marker : Right (R) side visible
  • Likely ICU patient (portable film)

Lines / Tubes

  • A tube is seen in the trachea → likely endotracheal tube (ET tube)
  • Position appears roughly within trachea, but exact tip level needs confirmation (ideal: 2–3 cm above carina)

Lung Findings

  • Bilateral lung opacities present
  • Left lung > Right lung involvement
  • Patchy / diffuse white areas → suggest:
  • Consolidation
  • Pulmonary edema or ARDS pattern

This correlates with your earlier note of:

  • Low SpO₂ (83%)
  • Low P/F ratio (<100)

Right Lung

  • Relatively more aerated (darker) compared to left
  • Still shows patchy involvement

Left Lung

  • Dense opacification (whiter)
  • Suggests:
  • Severe consolidation
  • Fluid-filled alveoli
  • Possibly dependent collapse or ARDS
  • Cardiac Silhouette
  • Appears slightly enlarged or obscured

Could be due to:

  • AP view magnification
  • Lung pathology masking borders

Pleura

  • No obvious large pneumothorax
  • Effusion not clearly defined (possible on left side but needs clinical correlation)

Chest X-ray (AP Bedside) – Interpretation

Date: 12-03-2026

View: AP bedside

Comparison Insight (vs previous X-ray)

  • This film appears improved compared to earlier one:
  • Less diffuse white-out
  • Better lung aeration
  • Lung Fields
  • Bilateral lung expansion improved

Residual findings:

  • Mild-to-moderate basal opacities
  • More on the lower right zone
  • Upper zones are relatively clearer

Suggests

  • Resolving ARDS / pulmonary edema
  • Residual basal consolidation or atelectasis
  • Right Lung
  • Patchy opacity in lower zone

Possible

  • Atelectasis
  • Residual consolidation
  • Small pleural effusion

Left Lung

  • Significantly cleared compared to prior
  • Mild basal haziness persists
  • Cardiac Silhouette
  • Appears within normal limits (considering AP view)
  • Pleura
  • No obvious pneumothorax
  • Possible minimal basal effusion (especially on the right side)

Devices / Lines

  • No obvious ET tube seen in this film
  • No clear ECMO cannula visible (may be removed or not in field)

Overall Impression

  • Interval improvement
  • Previously severe bilateral opacities → now partially resolved

Status likely

  • Recovering ARDS
  • Post ventilation / ECMO support improvement

Clinical Correlation

This X-ray suggests

  • Improved oxygenation likely
  • Weaning phase (ventilator/ECMO) possible

Continue monitoring for:

  • Basal collapse

Decannulation notes

Patient successfully weaned and de-cannulated from ECMO with stable hemodynamics and adequate oxygenation, patient stable, cannulas removed, hemostasis achieved.

  • No bleeding /hematoma
  • SpO2 – 100% on ventilator.

Reference

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  • Lafç G, Budak AB, Yener AÜ, Cicek OF. Use of extracorporeal membrane oxygenation in adults. Heart Lung Circ. 2014 Jan;23(1):10-23. [PubMed]
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  • Lepper PM, Barrett NA, Swol J, Lorusso R, Di Nardo M, Belliato M, Belohlavek J, et al. Perception of prolonged extracorporeal membrane oxygenation in Europe: an EuroELSO survey. Perfusion. 2020;35(1_suppl):81-85.doipubmed
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