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

mccollum2013

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:

Ho-bellezzo-SMACC-CHICAGO-THE-INTERVIEWS

#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

The Rat Pack: Another Year of EDECMO (2014/2015) – Video

EDECMO 24 – Weaning VA-ECMO, with Deirdre Murphy

In this episode, Zack and Joe talk with Deirdre Murphy, the Deputy Director of the ICU, director of the cardiothoracic ICU at the Alfred Hospital in Melbourne, Australia. The Alfred has put itself on the map in so many ways over the past decade. Home to Stephen Bernard (of the original Hypothermia after ROSC without RONF fame), Chris Nickson (@precordialthump, @ragepodcast, @intensiveblog, #SMACC, lifeinthefastlane.com), and good friends Jason McClure, Steve McGloughlin, Josh Ihle, Paul Nixon, and Deirdre Murphy, The Alfred is becoming a mecca for advanced resuscitation and ECMO/ECPR.  In this episode we sat down with Dr. Murphy to discuss the nuances of weaning a patient from ECMO.

As ED Docs, Zack and I find ourselves at the heroic end of the resuscitation spectrum when the dying patient goes on pump…but what happens at the other end? What happens in the hours, days, and weeks that follow?  Listen to this episode to find out…

 

Deirdre Murphy MB (Hons), MRCPI, FCARCSI, FCICM, DDU (Crit Care), PGDipEcho

Deirdre Murphy MB (Hons), MRCPI, FCARCSI, FCICM, DDU (Crit Care), PGDipEcho

Deirdre Murphy MB (Hons), MRCPI, FCARCSI, FCICM, DDU (Crit Care), PGDipEcho

Deirdre is Deputy Director ICU, Director of the Cardiothoracic ICU at The Alfred Hospital with particular interests in echocardiography and cardiac intensive care, especially mechanical circulatory supports including Ventricular Assist Devices and ECMO. Deirdre originally trained in Ireland with postgraduate training in general medicine and anaesthesia prior to undertaking intensive care training in Australia in 1999. She has been an Intensivist at The Alfred since 2003. Deirdre has been using echo in clinical practice since 2002 and heads the ICU echocardiography programme at the Alfred. She is convenor of the Alfred Critical Care Echocardiography Course and the Alfred TOE course and teaches on many of the other Alfred courses including the Ultrasound, ECMO and HeART courses.

A paper just published in Intensive Care Medicine followed this algorithm:

(Intensive Care Med (2015) 41:902-905)

How to wean a patient from veno-arterial extracorporeal membrane oxygenation

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Some Notes

Signs of improvement

  • Pulsatility indicates the patient is getting better
  • ETCO2 starts to rise
  • Weaning Vasopressors

 

Want More??

Check out Dr. Murphy's talk from smaccGOLD on “ECMO: What could go wrong?”

Also, check out the incredible resources on ECMO on the INTENSIVE blog (the Alfred ICU Education blog)

Update:

Can we use ETCO2 to assess weaning?

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