EDECMO 28 – The University of Utah EDECMO Experience and the ERECT Collaborative

The University of Utah ECPR Program

Joe TonnaJoe Tonna MD – Emergency Physician with fellowship training in intensive care, Associate Director of ECMO Services

 

Scott YoungquistScott Youngquist – Emergency Physician, Prehospital Specialist

 

Stephen McKellarSteven McKellar – CT Surgeon

 

 

 

 

 

 

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Building REANIMATE 1: a video montage

While preparing for #REANIMATE16 there were no simulators for ECPR. There were no commercially available models for ECPR cannulation. There was nothing.

We had to build it. From scratch.

This short video documents the building of #REANIMATE16: the first international endovascular resuscitation conference.

*special thanks to Jeremy Haywood for producing this video: jeremyhaywoodphotography.com

 

Thinking back on #REANIMATE16, I couldn't help but think of the iconic American movie ‘It's a Wonderful Life', featuring Jimmy Stewart. Although the audio soundbytes in this video may seem out of context, I hope the concept of ‘building' something from nothing was preserved:

~Joe

 

It's a Wonderful Life is a 1946 American Christmas fantasy drama film produced and directed by Frank Capra, based on the short story “The Greatest Gift”, which Philip Van Doren Stern wrote in 1939 and published privately in 1945. The film is now among the most popular in American cinema and because of numerous television showings in the 1980s has become traditional viewing during the Christmas season.

The film stars James Stewart as George Bailey, a man who has given up his dreams in order to help others, and whose imminent suicide on Christmas Eve brings about the intervention of his guardian angel, Clarence Odbody (Henry Travers). Clarence shows George all the lives he has touched and how different life in his community of Bedford Falls would be had he never been born.

Despite initially performing poorly financially because of high production costs and stiff competition at the time of its release, the film has come to be regarded as a classic. Theatrically, the film's break-even point was $6.3 million, approximately twice the production cost, a figure it never came close to achieving in its initial release. An appraisal in 2006 reported: “Although it was not the complete box office failure that today everyone believes … it was initially a major disappointment and confirmed, at least to the studios, that Capra was no longer capable of turning out the populist features that made his films the must-see, money-making events they once were.”[7]

It's a Wonderful Life is one of the most acclaimed films ever made, praised particularly for its writing. It was nominated for five Academy Awards including Best Picture and has been recognized by the American Film Institute as one of the 100 best American films ever made,placing number 11 on its initial 1998 greatest movie list, and number one on AFI's list of the most inspirational American films of all time. Capra revealed that the film was his personal favorite among those he directed, adding that he screened it for his family every Christmas season.

 

shinar bellezzo

EDECMO 27 – A Real-World Case of a Crashing Multi-Drug OD Patient Saved with ED ECMO

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Dan McCollum MD

Dan McCollum MD
Assistant Program Residency Director at Georgia Regents University
Augusta, Georgia
Academic Medical center, Level 1 Trauma Center: census >90,000/yr

“If someone is doing an effective therapy out of the back of a truck successfully, and you can’t make it work in your hospital, then you suck and should feel bad.”

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Case: 38 y/o female multi-drug OD on (possibly):

  1. Montelukast 10 mg (Singulair) – leukotriene receptor antagonist. mild tox profile (3698 pediatric ingestions from Texas Poison Control: 95% asymptomatic)
  2. Promethazine 25 mg (Phenergan) – Anticholinergic (56% tachycardia, 42% delirium, 2% mechanical ventilation, 1% hypotension)
  3. Cyproheptadine 4 mg  – Anticholinergic; mild tox profile (892% of OD in one case series had no or mild symptoms)
  4. Clonazepam 1 mg (Klonipin) – Common: respiratory depression and hypotension; Rare: heart block/dysrythmia
  5. Amitriptyline 25 mg – TCA – Hypotension.  QRS widening with R wave in AVR
    • Treatment:
      • antidote = sodium bicarbonate
      • crystalloid for hypotension
      • Pressors for refractory hypotension
  6. Amlodipine 5 mg – Calcium Channel Blocker – Common: Bradycardia, hypotension, heart block; Rare: apnea, pulmonary edema, ARDS, coma, Lactica acidosis, hypoerglycemia, bowel infarction
    • Treatment:
      1. IVF
      2. High Dose Calcium (inotrope)
      3. Pressors – Isoproterenol
      4. Glucagon
      5. Atropine
      6. High Dose Insulin – 1-10 unit/kg/hr infusion (consider simultaneous glucose infusion)

 

Timeline before ECMO:

  • 02:00-17:00     Estimated time of ingestion:  (2-15 hours PTA).
  • 19:00                 Presentation to ED
  • 19:30                 BP 55/33; sats 93% on 60% FiO2
  • 19:41                  PEA ARREST #1
    • Epinephrine, Atropine, Sodium Bicarbonate, Calcium Gluconate, D50
    • Narcan > No response
  • 19:54                  Bradycardia with pulse
  • 20:10                  Bicarbonate gtt
  • 20:15                  Epinephrine gtt
  • 20:18                  High Dose Insulin bolus, then gtt
  • 20:31                  TC pacing
  • 20:40                 Norepi gtt, Charcoal
  • 20:46                 CXR = pulmonary edema
  • 21:07                  Bivent initiation
  • 21:14                  Intralipid bolus
  • 21:16                  Glucagon
  • 21:21                  43/29 with sats 69% and pulse 70
  • 21:31                 pRBC transfusion initiated

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Total Meds used in resuscitation:

  • Calcium Gluconate:                21 Amps
  • Sodium Bicarbonate:             19 Ams
  • Epinephrine:                           9.5 mg + drips
  • Insulin:                                     ~150 units

Complications during hospitalization (but the patient is alive!):

  1. AF with RVR
  2. DVT
  3. ipsilateral limb ischemia > Necrotizing fasciitis > AKA
  4. Pleural Effusion > chest tube
  5. Bowel perforation (due to ischemia) > laparotomy
  6. Trach/PEG
  7. Abdominal Wall Abscess > I&D

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Learning Points:

  1. RUSH exam early for undifferentiated shock
  2. Restrictive lung strategy to avoid ARDS
  3. Multi-agent OD: contact Poison Control – they can actually help! 1-800-411-8080
  4. ECMO is a bridge to metabolism/recovery.

“If someone is doing an effective therapy out of the back of a truck successfully, and you can’t make it work in your hospital, then you suck and should feel bad.” – Dan

*and special thanks to Dan McCollum for creating and sharing the Napoleon Dynomite memes.

EDECMO 26 – “ECPR is a Step Too Far” – Ho vs. Bellezzo: a SMACCback Chicago Cage Match

CHRIS HO VS JOE BELLEZZO – ECPR IS A STEP TOO FAR

***republished with permission from the SMACC team from: http://www.smacc.net.au/2016/02/chris-ho-vs-joe-bellezzo-ecpr-is-a-step-too-far/

Are you ready for this rumble in the urban jungle?? Chris Ho vs Joe Bellezzo in the no holds barred debate about whether ECMO CPR is a step too far? The next cage match from SMACC Chicago.

Chris and Joe are the director and vice-director respectively, of Emergency Medicine at Sharp Memorial Hospital in San Diego, California. They are two of the leading experts in ECPR, with Joe being one of the key players behind EDECMO. On a day-to-day basis, they are friends and colleagues, working together in one of the very few centers around the world to deliver ECPR. However in this Cage Match, friends become foe and there are no limitations to how far each will go to prove their side of the debate.

On the AFFIRMATIVE side, Chris Ho delivers a convincing argument for why ECPR IS a step too far. From lack of evidence to the cost of “re-animating the dead” and everything in between, Chris Ho delivers a practical approach to the argument and demonstrates without a doubt why we are not ready for this to be the next step in resuscitation.

On the NEGATIVE side, Joe Bellezzo delivers an outstanding rebuttal to “Dr Ho’s Nutty Brown Bullshit”. In an inspiring argument filled with anecdotes and occasional facts, Joe Bellezzo makes it impossible to think the ECPR shouldn’t be the next step in our ALS algorithm,

Despite strong arguments from either side, as in all debates, there must be a winner. Do you agree with the outcome?

If you want to find out whether Chris and Joe were able to kiss and make up, check out the exclusive ICN interview with the two, where they discuss more on ECPR.

Also check out the ‘SMACCback' interview of Ho and Bellezzo by Sophie Connolly and Alice Young of the SMACC Chicago team:

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#REANIMATE16 would not have been possible without ‘a little help from our friends’ from the Alfred ICU

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REANIMATE 2: September 12 & 13, 2016

REANIMATE 1 is now behind us. And it was a “yoooooooge” success (Reanimators from R1 will get that one!) On February 25 and 26, 2016 physicians, nurses and paramedics from around the globe met at the UCSD Simulation Center/Center for the Future of Surgery and immersed ourselves in the art and science of Endovascular Resuscitation: ECMO, ECPR, REBOA, bleeding-edge resuscitation, and more.    From  the entertaining (and for Bellezzo maybe a little humiliating!) didactic sessions to hands-on down-and-dirty sim sessions, participants were given the opportunity to train with the best educators in the world of resuscitative science. And now we are ready to make it even better!

REANIMATE 1 sold out one week after opening registration. Those who couldn't get into REANIMATE 1 made it onto a  waiting list for R2, which  is selling out fast. Register NOW and don't miss out!

Check out the video:

EDECMO 25.5 – (Part 2) an EDECMO short with Jim Manning – on location with the SAMU pre-hospital ECMO team in France

In followup to our discussion with Jim Manning MD (@JManning_UNC)  and Lionel Lamhaut (@LionelLamhaut) MD of the Service d’Aide Médicale Urgente (SAMU) for EDECMO Episode 25, the guys spent the last few days ‘just hanging out in Paris.”

The recent massacre in Paris certainly makes this topic..well…topical.

Manning spent several days with the prehospital ECMO team in France.  In this episode Zack interviewed Manning, who was on-location with the SAMU in France…and walks us through the experience of witnessing prehospital ECMO with the SAMU.

In the U.S., we aren't yet ready for pre-hospital endovascular resuscitation – indeed there are currently several barriers to overcome. But perhaps the Europeans are onto something here:

Femoral cutdown vs. percutaneous access? Discussed. Verdict?

Transporting a patient on ECMO:

You know, the thing is…that once you have a patient on ECMO, everything chills out…

-Jim Manning

Every patient gets:

  • Dobutamine: 5 ug/kg/min
  • Norepinephrine 3 mg/hr
  • pRBC 2 units
  • FFP 2 units

Flow goals: start 2.5-3 lpm…then slowly increase. Does this help quell reperfusion injury?

This is the exciting. This is fantastic. This is the future if you ask me. We are going to be doing this and its just a matter of time before the rest of us realize that…we are headed in the right direction

Jim Manning

Jim Manning

SAMU Ambulance

SAMU Ambulance

Lionel Lamhaut and the SAMU ambulance

Lionel Lamhaut and the SAMU ambulance

Manning & SAMU

Manning & SAMU

EDECMO 25 – ‘Ze ECMO TEAM.’ Manning and Lamhaut: Updates on ECMO, the new 7F REBOA Catheter, and Pre-hospital ECMO in France

In this episode, Zack interviews Jim Manning MD (University of North Carolina) and Dr. Lionel Lamhaut of the famed French SAMU (Service d'Aide Médicale Urgente).

Highlights:

2015 Resuscitation Science Symposium updates:

“ECMO is at the forefront of resuscitation science” – Jim Manning

The New REBOA Catheter: Pryor Medical – just obtained FDA approval for endovascular proximal control of non-compressible hemorrhage below the diaphragm.

At Sharp Memorial Hospital we currently use the 12Fr Chek-Flo sheath, paired with 12F (external diameter) CODA balloon occlusion catheter for non-compressible hemorrhage below the diaphragm.  Pryor Medical has just gained FDA approval to market their REBOA catheter – a 7F version that doesn't seem to require surgical repair of the arteriotomy site.  For those of us doing REBOA, this is a BIG DEAL:

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Selective Aortic Arch Perfusion Catheter (SAAP) – which is like a REBOA catheter but has a lumen large enough to perfuse blood (or a blood substitute) through.  Manning talks about what's sexy with his device.

 

Lionel Lamhaut from the French SAMU (Service d'Aide Médicale Urgente) gives us an update on their prehospital ECMO program in France:

SAMU Inclusion Criteria:

  1. Medical Cardiac Arrest
  2. Age < 75
  3. No Flow < 5 min (bystander CPR must be started within 5 min)
  4. Hypothermia is always considered
  5. Intoxications (of any kind) are always considered
  6. ETCO2 > 10

For review, check out our original discussion with ‘reanimateur' Dr. Lamhaut about prehospital ECMO: edecmo.org/17

In keeping with all of the in-hospital and out-of-hospital ECPR data accumulating, it appears that Lamhaut's team is also seeing a success rate (survival with CPC 1 or 2) of around 30% (final data pending publication).

 

Consider this: the modified cut-down technique. The French prehospital team, quite obviously, don't have ultrasound access in the field.  So instead of using ultrasound visualization of the femoral vessels, they necessarily use direct visualization.  Listen to this episode to hear the details…

 

 

 

 

Torsades De Pointes with Rob Orman from ERCAST

This month Joe was honored to be a guest on Rob Orman's famed Podcast ERCast. Joe and Rob define Torsades de Pointes, talk about management, and explain why OVERDRIVE pacing isn't a real thing in the Emergency Department.

Check it out:

http://blog.ercast.org/torsades-de-pointes/

The Birth of a Legend: #HollywoodWeingart

The Essentials of Emergency Medicine 2015 was AMAZING, in so many ways.  One thing, in particular, stood out amongst others… The Birth of a LEGEND. Take a look at how a true legend is born:

 

Hollywood Weingart Trailer from Joe Bellezzo on Vimeo.

Haney Mallemat MD, Anand Swaminathan MD, Scott Weingart MD, Zack Shinar MD, Rob Orman MD