4: Rescue VV ECMO for Catastrophic Airway Injury Following Suicide Attempt: A Lifesaving Intervention in a CICO Emergency

Background: Tracheobronchial injuries are rare but life-threatening emergencies that demand rapid and coordinated management. In cases of catastrophic airway disruption, conventional airway techniques may fail, resulting in a “cannot intubate, cannot oxygenate” (CICO) scenario. Extracorporeal membrane oxygenation (ECMO) has emerged as a valuable adjunct to support oxygenation and ventilation in such circumstances. Case Presentation: A 44-year-old male presented with a severe anterior neck injury following a suicide attempt. Initial airway management at a referring hospital involved placement of an endotracheal tube through a tracheal defect, followed by urgent transfer to a tertiary center. On arrival, the patient was profoundly hypoxic (SpO2 40%) with extensive cervical trauma, including multilevel transections of the thyroid and cricoid cartilages and complete tracheal transection below the thyroid cartilage. Severe subcutaneous emphysema and distorted anatomy rendered conventional airway access unfeasible. Management and Outcome: The patient was transferred emergently to the operating theatre, where a multidisciplinary team determined that definitive airway control could not be safely achieved. Veno-venous ECMO (VV ECMO) was rapidly initiated via femoral cannulation, resulting in immediate stabilization of oxygenation and allowing safe surgical exploration. The otolaryngology team performed staged laryngotracheal reconstruction. Postoperatively, imaging demonstrated thyroid cartilage fracture and extensive emphysema. The patient was managed in the intensive care unit with corticosteroids, antibiotics, and tracheostomy. Progressive respiratory and neurological improvement permitted successful VV ECMO decannulation and transition to spontaneous ventilation. The tracheostomy was subsequently downsized, and the patient was discharged from the ICU for psychiatric evaluation and rehabilitation. Conclusion: This case underscores the critical role of VV ECMO as a lifesaving bridge in catastrophic airway trauma when conventional airway management is impossible. Early recognition of CICO physiology, prompt ECMO initiation, and effective multidisciplinary collaboration are key factors in improving outcomes in complex airway emergencies.