Abstract Background The use of extracorporeal membrane oxygenation (ECMO) in trauma patients remains limited due to bleeding risk, complex physiology, and uncertain benefit following cardiac arrest. Refractory hypercapnic respiratory failure secondary to aspiration pneumonitis is an uncommon but devastating complication. We present a case in which venovenous VV-ECMO provided physiologic stabilization and organ preservation after traumatic cardiac arrest and aspiration, culminating in organ donation. Case Presentation A 57-year-old male presented as a trauma activation following a motorcycle collision. He suffered pulseless electrical activity arrest at the scene, receiving 26 minutes of cardiopulmonary resuscitation (CPR) with return of spontaneous circulation. On arrival, he was in mixed cardiogenic and hypovolemic shock, intubated, and profoundly acidotic (pH 7.0, PaCO2 125 mmHg) despite maximal ventilatory support (FiO2 1.0, PEEP 16 cmH2O, plateau 30 cmH2O). Trauma imaging revealed bilateral aspiration pneumonitis and a thoracic vertebrae compression deformity. Bronchoscopy showed severe bronchial inflammation and undigested peppers and onions. Echocardiography showed global left ventricle dysfunction (EF 20-30%).Despite maximal ventilatory and medical optimization, the patient’s hypercapnia and acidosis persisted. After multidisciplinary consultation, VV-ECMO was initiated via bilateral femoral venous cannulation (25 Fr). Low flows prompted conversion to femoral-internal jugular configuration (20 Fr IJ return). ECMO flows reached 3.4 L/min, sweep 2.0 L/min, normalizing pH and PaCO2 and supporting systemic perfusion.Neurologic exam revealed no brainstem reflexes despite normothermia, hemodynamic stability, and correction of metabolic derangements. Brain death was confirmed by two physicians and formal apnea testing. After family discussions, the patient was transitioned to organ donation. ECMO support was continued for end-organ preservation, and kidneys and liver were procured for transplantation. Discussion This case underscores the expanding indications and implications of ECMO in trauma care. It is, to our knowledge, among the first documented instances of VV-ECMO used for refractory hypercapnia secondary to massive aspiration following traumatic cardiac arrest, serving as a bridge to organ donation. The physiologic novelty lies in demonstrating that even after prolonged CPR and profound respiratory acidosis, extracorporeal support can restore systemic homeostasis sufficient to maintain viable organ perfusion.This report challenges traditional futility thresholds in ECMO selection, suggesting that trauma-associated cardiac arrest and severe aspiration are not absolute contraindications when end-organ preservation remains achievable. This reframes the purpose from salvage therapy to ethical stewardship of viable organs. Furthermore, it raises critical questions regarding resource allocation, timing of neurologic prognostication, and integration of ECMO into donation-after-brain-death protocols. This abstract is funded by: none
Gray et al. (Fri,) studied this question.