Veno-Venous ECMO after Penetrating Trauma: A Viable Option With Individualized Anticoagulation

Background The incidence, clinical characteristics, complications, and outcomes for extracorporeal membrane oxygenation (ECMO) in penetrating trauma cases are mostly unknown. The purpose of this study was to evaluate the concept that ECMO could be a safe and effective therapy after severe penetrating injury at a single high-volume center. Methods We conducted a retrospective case series of all penetrating trauma patients supported with ECMO at a single Level I trauma center between January 2022 and June 2025. Data collected included demographics, injury patterns, ECMO indications and cannulation details, anticoagulation management, operative interventions performed on ECMO, bleeding and thrombotic complications, and clinical outcomes. Results Eight patients were supported with veno-venous ECMO, all male, with a median age of 36 years and a median Injury Severity Score of 20. Injury mechanisms included six gunshot wounds and two stab wounds, with a median PaO2/FiO2 ratio of 71 at ECMO consultation. Anticoagulation was individualized, with initiation delayed a median of 4 days after cannulation, and one patient received no anticoagulation throughout their ECMO course. Four patients underwent major operative procedures while on ECMO. Three patients had manageable bleeding complications, and three had thrombotic complications not associated with anticoagulation interruption. Overall survival to hospital discharge was 75% (6/8 patients). Discussion This case series demonstrates basic proof of concept that ECMO can be safely implemented in carefully selected penetrating trauma patients. Individualized anticoagulation strategies and concurrent operative management were feasible with manageable complications. Further multicenter studies are needed to define optimal patient selection and anticoagulation practices.