A modern ICU dilemma: should some patients be considered for immediate extracorporeal support without trial of invasive ventilation?
Extracorporeal membrane oxygenation (ECMO) is indicated in management of severe reversible respiratory failure. It is used primarily as a rescue treatment when conventional ventilation has failed (1). As ECMO improves and becomes increasingly available with advances in technology and practice there is an argument it could be considered first line therapy in certain cases. It has been trialled in awake, self-ventilating patients as a bridge for lung transplantation with positive results (2). Some centres are considering ECMO as a first line treatment in acute respiratory failure but there is currently a lack of supporting clinical evidence (3).
A 23 year old male was admitted with isolated chest trauma following a road traffic accident in which he was knocked from a moped onto his right side.
CT scan revealed multiple rib fractures, bilateral lung contusions, pulmonary haemorrhage and a large right sided lung cavity of unknown chronicity or aetiology (Image 1&2).
Bilateral thoracotomies were performed and chest drains inserted pre-hospital although acute surgical intervention was not indicated.