• ECMO
• abdominal compartment syndrome
• lung injury

A 64-year-old woman who had been hit by a train presented to the emergency department with bilateral upper limb and left lower limb crush injuries. The patient’s pulse was 134 beats per minute; blood pressure, 78/44 mm Hg; and respiratory rate, 30 breaths per minute. She was intubated, and initial resuscitation was started immediately.

During the primary survey, a left-sided hemothorax causing hemorrhagic shock was noted and massive bloody discharge via a chest drain was observed. She underwent left thoracotomy and wedge resection of the injured lung using a staple device in the left lower lobe. In addition, she underwent bilateral forearm and left above knee amputation. The gas exchange deteriorated intraoperatively owing to massive transfusion and lung contusion. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) was initiated without heparin. An extracorporeal circuit was constructed in a veno-venous configuration, with femoro-jugular flow direction (figure 1). Consequently, the hemodynamic status and gas exchange improved rapidly. On transfusing 10 L of crystalloids and 50 units of blood products, the VV-ECMO blood flow gradually reduced to 0.8 L/min and blood oxygen saturation deteriorated to 68%. Based on the patient’s overall condition, the massive bleeding had likely been arrested. The abdomen was distended, but focused …