A42-13 Cocaine Induced Diffuse Alveolar Hemorrhage Resulting in Fulminant Hypoxemic Respiratory Failure Requiring VV-ECMO

Abstract A 38-year-old male with a past medical history of anxiety and polysubstance abuse was brought to the emergency department in the setting of severe shortness of breath, drowsiness, and a mild cough associated with a small amount of blood after recent inhalation of cocaine. He was initially placed on a non-rebreather mask, then escalated to BIPAP, and eventually intubated for persistent hypoxemia. CT chest revealed diffuse bilateral alveolar infiltrates and consolidation concerning of DAH (Fig.1). Despite lung-protective mechanical ventilation, hypoxemia persisted, necessitating escalation to veno-venous extracorporeal membrane oxygenation (VV-ECMO) within 4 hours from presentation. Diagnostic bronchoscopy demonstrated copious, progressively bloody lavage, highly suggestive of diffuse alveolar hemorrhage (DAH). Pulse dose of methylprednisolone was initiated. Autoimmune serologies were negative, excluding vasculitis and other systemic causes. Over the subsequent days, his lung compliance and oxygenation gradually improved. Repeat bronchoscopy on hospital day 5 showed resolution of bloody secretions. On day 9, he was successfully extubated, and on day 11, he was decannulated from VV-ECMO. Ultimately, he was discharged from the hospital with near-baseline respiratory function. Cocaine inhalation is a recognized cause of DAH, attributed to direct alveolar-capillary membrane injury and vasoconstriction, leading to bleeding and severe hypoxemia. CT typically demonstrates diffuse ground-glass opacities and consolidation, but findings are nonspecific and must be interpreted in the context of substance use. Management is primarily supportive, with corticosteroids considered in cases of suspected vasculitis, though evidence for their efficacy in cocaine-induced DAH is limited. VV-ECMO is indicated in severe, refractory hypoxemic respiratory failure when conventional ventilation fails, as in this case. The EOLIA and CESAR trials support ECMO for patients with severe ARDS (PaO2/FiO2 80 mmHg for 6 hours or 50 mmHg for 3 hours), demonstrating improved survival and quality-adjusted life years. Although DAH is traditionally considered a relative contraindication to ECMO due to bleeding risk, recent case series and registry data show that modern ECMO technology allows for lower anticoagulation targets, reducing hemorrhagic complications and supporting its use in DAH. In a series of patients with DAH managed with VV-ECMO, survival to decannulation was 100%, with 75% surviving to discharge. This case highlights the importance of early recognition of cocaine-induced DAH and the role of VV-ECMO in managing refractory hypoxemia. Multidisciplinary care, including critical care, pulmonology, and toxicology, is essential. The prognosis depends on the severity of hemorrhage, underlying comorbidities, and timing of ECMO initiation. This abstract is funded by: None