EDECMO 41 – The 3 Stages of ECPR – Diane’s Story

[The original EDECMO 41 post had to be taken down…for reasons beyond our control! But here is the new and improved Episode 41]

In this episode Zack and Joe discuss the 3-stages of Extracorporeal Membrane Oxygenation (ECMO) – or put another way, this is how to start Extracorporeal Cardiopulmonary Resuscitation (ECPR) in the Emergency Department (ED). It’s been 4 years since we talked about these basic premises of ECPR. But this time, its highlighted in a very special story.

The Three Stages of ECPR:

  1. Placement of any commercially available catheters into the femoral artery and femoral vein.
    • Ultrasound-guided percutaneous access is our preference, but cutdown is also considered.  This is done in every patient, every time, and is done in parallel to ongoing ACLS. Transduce the arterial line to guide resuscitation and use the venous line for resuscitation purposes.
  2. Transition to ECMO cannulas
    • Using guidewires (we prefer the Amplatz Super Stiff 145 cm .038″ teflon coated floppy tip wires), remove the catheters placed in Stage 1, perform serial dilation, and place ECMO cannulas
  3. Initiate the ECMO pump
    • Perform ‘underwater seal’ using crystalloid, which closes the circuit.  The circuit is de-aired and the pump is started.  Increase the RPM to 1500 and remove the clamps.  Inspect the circuit and troubleshoot any issues.

3 stages. 3 steps.

You can find a whole lot more on our ECPR 3 stages page.

EVEN BETTER! If you are interested in learning all about ED ECMO, with hands-on simulators, Wold-renowned ECMO educators, REBOA, ECPR, computer simulation, check out the REANIMATE conference site or go directly to the REANIMATE registration page!!

 

Diane’s Story:

November 30, 2017: Diane suffered ventricular fibrillation (VF) cardiac arrest and collapsed…just outside the ED doors.  CPR was started immediately by an ED nurse. After 32 minutes of failed Advanced Cardiac Life Support (ACLS), with human and mechanical chest compressions, she remained in refractory VF.

Our Emergency Physician-initiated ECMO (ED-ECMO) protocol was initiated using the ‘3 stages of ECMO.’   Diane was ‘on pump’ in 32 minutes, taken to the cath lab, and had her 95% LAD lesion stented by Interventional Cardiologist Arvin Narula.

Diane went home with her family and friends on December 13, 2017.  Listen to the episode to hear the details…

Diane’s Widowmaker

 

 

Dr. Narula, Interventional Cardiology

Joe and Diane

Diane with Casey Gwynn and sister Joanne

Dr. Eads and Diane

Zack Shinar, Diane, and Jessica

Bellezzo And Diane

EDECMO Episode 41 is REPOSTED

The original post for EDECMO 41 had to be permanently removed from the internet (for reasons beyond our control!!!) but its back. Click this link to take you to the new and improved (and HIPAA-compliant!!) episode: EDECMO 41 – The 3 stages of ECMO – Diane’s Story

2016 ECMO CPT Codes, RVUs, and MediCare Reimbursement

Ok, so we just crashed an arrested patient onto ECMO and he is going to the cath lab. Now, how do I document the procedure again?  What was the CPT for percutanous cannulation for VA-ECMO?  Does my billing company even know?

Bookmark this page for future quick reference of the current CPT codes, RVU values and MediCare reimbursements.

REANIMATE 4 Mashup Video!

REANIMATE 4 was THE best conference event I’ve ever had the pleasure to be associated with!  Take a look at this short video mashup of the entire event (and thanks to Jeremy Haywood, our videographer, video editor, and video producer)

For those of you who attended, thank you for bringing your “A-Game”!  Ya’ll came prepared and motivated! Your energy and devotion has completely re-energized us!  It was a little bittersweet when we all had to part ways on Friday. But welcome to the REANIMATE family!

If you couldn’t make it to “R4”, now’s the time to register for REANIMATE 5, which will be March 8-9, 2018 in San Diego.

REANIMATE 4 Video Mashup from Joe Bellezzo on Vimeo.

EDECMO 38 – ECMO and Trauma – with Pal Ager-Wick and Magnus Larsson

ECMO in trauma

This episode is all about ECMO in trauma – not the usual ARDS, TRALI VV-ECMO – we’re talking about VA ECMO for the acutely dying trauma patient. Zack interviews Pål Ager-Wick from Tromso Norway, and Magnus Larsson from the Karolinska Institute in Stockholm. We talk about everything from how ECMO helps the hemorrhaging trauma patient to the futuristic “Emergency Preservation and Resuscitation” concept being done in Baltimore now.

Photo used with permission of SAMU of Paris


Bullet Points:

  • VV ECMO –
    • Marginal data suggests ECMO beneficial in ARDS (CESAR, ANZECMO trials)
    • ARDS and TRALI in trauma is a reasonable extension of this
  • Damage Control Surgery –
    • focus on coagulation
    • stop major bleeders and then take to ICU
    • lethal triad of coagulation includes hypothermia, dilution of coagulation factors and acidosis
  • Coagulation of trauma: ECMO can improve all three components of lethal triad
  • Heparin has been successfully withheld in bleeding trauma patients
  • ECMO in Severe Chest Trauma – 10 patients, 8 ruptured cardiac chambers1
  • Blunt cardiac arrest – a case report2
  • Bleeding less than 15% mortality after 1995, Intracranial hemorrhage patients can survive. In fact none of the ICH patients on ECMO who died died of brain bleeding (60-93% survived). Survival was 42-63% for VA ECMO. Lower ACT (<180 sec)3
  • ELSO – VA ECMO in trauma – 45% survival4
  • ECMO reduces venous pressure which may be beneficial in hemorrhaging patients5
  • Tisherman – Suspended Animation: Emergency Preservation and Resuscitation678

Magnus Larsson

References

1.
Huh U, Song S, Chung S, et al. Is Extracorporeal Cardiopulmonary Resuscitation Practical in Severe Chest Trauma? : A Systematic Review in Single Center of Developing Country. J Trauma Acute Care Surg. August 2017. [PubMed]
2.
Kudo S, Tanaka K, Okada K, Takemura T. Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture: A case report. Am J Emerg Med. August 2017. [PubMed]
3.
Bedeir K, Seethala R, Kelly E. Extracorporeal life support in trauma: Worth the risks? A systematic review of published series. J Trauma Acute Care Surg. 2017;82(2):400-406. [PubMed]
4.
ELSO Registry. Extracoporeal Life Support Organization. http://www.elso.org/Registry/Statistics/InternationalSummary.aspx.
5.
Larsson M, Talving P, Palmér K, Frenckner B, Riddez L, Broomé M. Experimental extracorporeal membrane oxygenation reduces central venous pressure: an adjunct to control of venous hemorrhage? Perfusion. 2010;25(4):217-223. [PubMed]
6.
Tisherman S, Safar P, Radovsky A, Peitzman A, Sterz F, Kuboyama K. Therapeutic deep hypothermic circulatory arrest in dogs: a resuscitation modality for hemorrhagic shock with “irreparable” injury. J Trauma. 1990;30(7):836-847. [PubMed]
7.
Tisherman S. Salvage techniques in traumatic cardiac arrest: thoracotomy, extracorporeal life support, and therapeutic hypothermia. Curr Opin Crit Care. 2013;19(6):594-598. [PubMed]
8.
Kutcher M, Forsythe R, Tisherman S. Emergency preservation and resuscitation for cardiac arrest from trauma. Int J Surg. 2016;33(Pt B):209-212. [PubMed]

REANIMATE 5: March 8-9, 2018

REANIMATE 5 will be on March 8-9, 2018 in San Diego, California.

Registration will open on September 21, 2017. Announcements will precede!  But if you want to guarantee a spot at R5, put yourself on the Reanimate 5 Pre-Reg list.  REANIMATE sells out quickly. People are always asking how to guarantee their spot. This is the ‘ticket’!!!

ECMO, ECPR, REBOA, TEE, & Bleeding-Edge Resuscitation

Special Guest Faculty Member: Resuscitationist and interventional cardiologist Demetris Yannopoulos from the University of Minnesota. For more on Demetris’ recent contributions to ECPR:

EDECMO 36 – Crushing the Nihilism of Cardiac Arrest – with Demetris Yannopoulos

Crash Episode – MicroDissection of Yannopoulos’ ECMO Method

For more information on the Conference: reanimateconference.com

 

Don’t forget to get your name on the Pre-Registration List for REANIMATE 5 NOW!

 

 

 

 

 

EDECMO 37 – Nate’s Story

Jake is an Emergency Physician from Santa Cruz California whose interest in resuscitation was put to the fullest test when his own son had a cardiac arrest. This is the amazing retelling of that day in November when what Jake learned in an EDECMO workshop was utilized in a dramatic fashion. This is a story of two heros: Jake and his son Nate.

Haney Mallemat Endorses REANIMATE 4!

LEARN SOME EDUCATION!!!

-Haney Mallemat (@CriticalCareNow)

 

At Castlefest/Resusfest 2017 I caught up with Dr. Haney Mallemat and asked him to opine on our upcoming REANIMATE 4 conference on September 21-22, 2017. Haney did not disappoint! Check it out:

 

Haney Mallemat endorsing our REANIMATE 4 conference – Sept 21-22, 2017 from Joe Bellezzo on Vimeo.

EDECMO 36 – Crushing the Nihilism of Cardiac Arrest – with Demetris Yannopoulos

…all acute injury to the heart is reversible.

 

Demetris Yannapoulos
University of Minnesota

In this podcast episode, Zack interviews Demetris Yannopoulos from the University of Minnesota. Demetris has organized Minneapolis into arguably the most impressive ECPR city in the world. He has changed the mindset of out of hospital refractory ventricular fibrillation care from “stay and play”, the philosophy that medics should stay at the scene and provide care until ROSC (return of spontaneous circulation) or until the patient is pronounced dead. In Minneapolis, a patient who who arrests in  Yannopoulos’ catchment area gets three shocks. If the patient does not get ROSC then they are immediately transported to the University of Minnesota using LUCAS mechanical chest compression device. The patient bypasses the emergency department and goes directly to the cath lab. In the cath lab, Demetris, or one of his partners, cannulates and initiates ECMO with an average time of 6 minutes!!! In his first 90 patients he has had a 45% neurologically intact survivorship. Patients are getting to the cath lab on average 60 minutes after their arrest. In this cohort, you would expect a less than 1% survival. We can use Dr. Yannopoulos’ model to expand the use of ECPR in many other systems. The real question is do we have champions like Demetris who will rise to the calling!

#REANIMATE4 Tickets Go On-Sale March 2, 2017!

REANIMATE 4, the World’s only Endovascular Resuscitation Conference, is happening again on September 21-22, 2017!  Guest Faculty will include Scott Weingart, Zack Shinar, Joe Bellezzo, Chris Ho, Chris Nickson and STEVEN BERNARD (Yes! STEVE Friggin’ BERNARD! — 2002 Bernard Hypothermia trials, CHEER, The Alfred).

To REGISTER, go to: www.reanimateconference.com/register

This Conference sells out within weeks of promotion so don’t wait.

Want a taste of REANIMATE Goodness:

Reanimate 2 Highlight Video from Joe Bellezzo on Vimeo.