SMACCback Chicago: Ho & Bellezzo

Sophie Connolly and Alice Young from the SMACC Chicago team interviewed Dr. Chris Ho (Chief of Emergency Medicine at Sharp Memorial Hospital) and me (Joe) after our infamous cage match – where we debated the utility of ECPR.  Check out the SMACCback interview on the Intensive Network:

Ho-bellezzo-SMACC-CHICAGO-THE-INTERVIEWS

Or download the interview from iTunes

 

Reanimate 2016: RN spots still available! Bring the whole crew!

RN spots still available…bring your crew and learn the team approach to ECPR and Endovascular Resuscitation…

www.reanimateconference.com

EDECMO 23 – ORNATO LIVES! – How ECMO Saved a Pillar of Resuscitation

Dept of Emergency Medicine_Joseph Ornato_MD

Dept of Emergency Medicine. Joseph Ornato MD

“They RSI'd me…they cannulated me…

Here I am today, two months later…”

Joe Ornato, a pillar in the world of resuscitation, suffered a massive PE and arrested upon arrival to the Virginia Commonwealth University Emergency Department in April 2015.  First: hats off!!! to the Emergency Department, the resuscitation team, the CT surgeons and entire staff at VCU. How it all unfolded is amazing! You MUST listen to this episode to hear the details…

Joseph P. Ornato, MD, FACP, FACC, FACEP

Dr. Joseph P. Ornato is professor and chairman of the Department of Emergency Medicine at Virginia Commonwealth University Medical Center in Richmond, Virginia. He is also medical director of the Richmond Ambulance Authority, the Prehospital Paramedic System serving Richmond, Va. Dr. Ornato is triple board certified (internal medicine, cardiology, emergency medicine) and is an active researcher in the field of cardiopulmonary resuscitation. Dr. Ornato is an editor of the journal Resuscitation. He is past Chairman of the American Heart Association's (AHA) National Emergency Cardiovascular Care Committee and its Advanced Cardiac Life Support Subcommittee. He chaired the National Steering Committee on the NIH Public Access Defibrillation Trial. He is currently consultant and cardiac co-chairman of the NIH Resuscitation Outcomes Consortium (ROC) and serves as principal investigator for VCU on the NIH-sponsored Neurological Emergency Treatment Trials (NETT) Network. Dr. Ornato is a member of the Institute of Medicine.

Ornato and EMS team

Dr. Ornato and the prehospital trauma team

joe-ornato-photo-4_10937792

 

We lose the equivalent of one medium sized American city to the problem of sudden, unexpected cardiac arrest each year. The best weapon we have against this killer is early defibrillation. We need to move quickly to saturate the chain of survival, particularly the early defibrillation  component, in every community.”

-Joe Ornato, MD, FACC, FACEP

#EEM15 is just around the corner…

Register HERE…Screen Shot 2015-07-14 at 12.06.04 AM

We Will Miss You, John Hinds

I am a motoryclist, but never to the extent, passion or expertise of @docjohnhinds.

I am a doctor, but never to the extent, passion or expertise of @docjohnhinds

I am a resuscitationist, but never to the extent, passion or expertise of @docjohnhinds.

I didn't know John Hinds until I met him for the first time at SMACC Chicago 2 weeks ago:

Screen Shot 2015-07-05 at 10.10.56 AMBut I knew much about this amazing man because he was a legend in the resuscitation and trauma world. John was one of the “flying doctors” who dedicated a significant amount of time to caring for motorcycle road racers after life-threatening crashes.  He would ride right behind racers at near-racing speeds so he could be there in the first few seconds after a catastrophe.  He was the reason many men, who should've died, were able to survive. He was a legend in Northern Ireland.

Sadly, John was killed July 3, 2015 while providing medical coverage for  a Skerries 100 practice session.

It wasn't more than a few weeks ago that John gave an amazing talk at #smaccUS on his passion for motorcycles, resuscitation, intensive care, and motorcycle racing.  He was actively lobbying for an air-rescue helicopter system in Northern Ireland.

I only knew John for a moment. But in the wake if his work in Northern Ireland, and across the World, his legacy will live on.  In the last couple days, there has been an outpouring of support from everyone who knew him…

 

DeathIsAWanker-3
Hinds talking at SMACC

 

Hinds wheely

EDECMO 22 – Managing the Crashing Tox Patient with ECMO – with Leon Gussow & Steve Aks from The Poison Review

 

…the key thing is to put them on ECMO when they need it, but not a minute sooner!

-Leon Gussow

In this episode Scott, Zack and Joe were all in the same room…in a conference room at the University of North Carolina, Chapel Hill – where we were doing ECPR studies in an animal model of cardiac arrest with Jim Manning. We spoke with legendary toxicologists Leon Gussow and Steve Aks about the role of ECMO and ECPR in the overdosed tox patient.

This is a fascinating discussion about the nuances of ECMO in the crashing intoxicated patient.

Check out THE POISON REVIEW and Subscribe to them in iTunes

GussowLeon Gussow MD,

University of Illinois Medical Center, Chicago
John H. Stroger Jr. Hospital of Cook County
Emergency Medicine News “Toxicology Rounds”
Medical Editor of ‘The Poison Review”

aks-1-186x250

Steve Aks DO, FACMT, FACOEP, FACEP

Director, Toxicology Fellowship Program, Department of Emergency Medicine, Cook County Health and Hospitals System


 

Some Unique Situations:

ECMO and intralipid?

  • What are the adverse effects associated with the combined use of intravenous lipid emulsion and extracorporeal membrane oxygenation in the poisoned patient. Clin Toxicol (Phila). 2015 Mar;53(3):145-50. doi: 10.3109/15563650.2015.1004582. Epub 2015 Jan 29.
  • Bolus dose intralipid before ECMO is reasonable and should not result in significant pump complications with our current oxygenators.  However, starting intra-lipid after the patient is on bypass won't likely provide much more benefit and could shorten the life of your oxygenator.

ECMO and Dialysis?

  • Hemodialysis can be done in-line with the ECMO circuit, but its preferred to use a separate dialysis catheter placed at a remote site (ie the IJ).  A dialysis circuit CAN be spliced into the ECMO circuit, but is a little more complicated.

Mitochondrial and Cellular Respiration Poisons (dinitrophenol & Cyanid) and Carbon Monoxide?

  • ECMO is of NO USE in these intoxications.

REANIMATE SAN DIEGO 2016: February 25-26, 2016

REANIMATE SAN DIEGO 2016:       February 25-26, 2016 in beautiful San Diego, California, USA.

ABOUT THE CONFERENCE:

REANIMATE is a 2-day conference that will teach you everything about Resuscitative ECMO and Extracorporeal Cardiopulmonary Resuscitation (ECPR). Multidisciplinary teamwork and human factors will be stressed throughout. Sessions will have a heavy emphasis on acquiring hands-on skills associated with initiation of ECMO including:

  • Cannulation Technique
  • ECMO Physiology
  • Pump Troubleshooting
  • Cardiac Arrest & Peri-ECMO Resuscitation

ABOUT THE FACULTY:

The REANIMATE faculty will include some of the brightest minds in all of Resuscitation Medicine. The EDECMO team will be joined by some of the best teachers in the ECMO world. Check out the Faculty Page to see more about our incredible professors. Also check out the Schedule of Events.

ABOUT THE LOCATION

REANIMATE will be held at the UCSD Simulation Center in San Diego, California. The Sim Center offers gorgeous classrooms and state of the art simulation capabilities. The surrounding area is amazing. Torrey Pines golf course and recreation center are a short walk away. Beaches with surfing, volleyball and swimming are also within 3 miles of the Sim Center. The conference will make use of these areas with a beach trip and hiking of Torrey Pines on the agenda.UCSD Med Ed buildingvode_ucsd_telemed_01-resized-600

 

February is one of the most beautiful times of the year to visit San Diego.  Bring the family and make it a vacation!

REGISTER TODAY! space is limited

EDECMO 21- The Vienna Project: A Randomized-Controlled Trial of ECPR for Out-Of-Hospital Cardiac Arrest


SchoberAndreas Schober is an Emergency Medicine physician and resuscitationist from the Medical University of Vienna. Dr. Schober is a world-expert in resuscitation, ECPR, and cardiac arrest. We met Schober in Chicago at the 2014 American Heart Association (AHA) Resuscitation Symposium (ReSS) where he presented their experience with a “Load & Go” model for out-of-hospital cardiac arrest (OHCA): Screen Shot 2015-05-01 at 10.08.03 PM


In this episode Zack talks with Dr. Schoeber about their newest endeavor, the holy grail: a randomized-controlled trial comparing “Load & Go” (transporting OHCA patients to the ED immediately for consideration of ECMO) vs. “standard care” (staying on scene until the patient achieves either ROSC or is pronounced dead).  Zack and Andreas talk about the impact this could have on the future of ECPR for OHCA.

Announcements:

SMACC Chicago 2015: There is still time to register for SMACC – the biggest and baddest ED Critical Care conference in the World. Just check out the lineup of speakers! You won't want to miss this.

Reanimate San Diego 2016:  The EDECMO team has put together a crew of world-class educators to teach you how to set up an ED ECMO program, teach you how to initiate ECPR in arresting patients, and teach you how to manage patients after they are on “on-pump”. Please join us in “America's Finest City,” San Diego, California, for 2-day immersion in ECPR. We are limiting the conference size to maximize your learning experience, so registration will sell out quickly:

Register for Reanimate San Diego 2016

 

**Special thanks to Camille Hudon for providing the “International Introduction”, in French, to this episode!!!  That was recorded in a small restaurant in Montreal during Bring Me Back To Life 2014

 

 

The BEST Vascular Access Phantom for ECPR Simulation

Jacob Avila, MD, RDMS,  from 5minsono shared this video of his recipe for making the ULTIMATE ultrasound-friendly vascular access phantom.  Jacob hosts the www.5minsono.com site.

Jacob introduced us to this ballistic gel phantom for our ED ECMO Workshop at Castlefest 2015 and it worked wonderfully.  Each phantom was able to accept multiple cannulations with 21 Fr cannulas!  And when we were  done we just melted them down and made new phantoms.

If you need the ultimate recipe for making ultrasound-friendly vascular access phantoms, check out Jacob's site and use this recipe.

EDECMO-endorsed!  Thanks, Jacob!

EDECMO 20 – The Golden Hour & the Rule of 3’s: Optimizing the Critical First Hour on Heart-Lung Bypass

Announcements

Upcoming Conferences:

  1. SMACC 2015: June 23-26, 2015. The biggest and baddest critical care conference of the year is in Chicago this year.
  2. Essentials of Emergency Medicine 2015. October 13-15, 2015. The Big Show. In Vegas. At the Cosmopolitan.
  3. Reanimate San Diego. February 25-26, 2016. The essentials of ECMO in 2 glorious days. Here is a sneak peak at the Reanimate 2016 Promo Video.

Flipped Classroom SMACC ECMO Workshop 2015

For those taking the upcoming ECMO courses with us, download both of these 2 attachments. The first is a diagram of a traditional ECMO circuit – its nice to print this out and follow along. Not every circuit is the same and we have ours custom built by Maquet.  The second is a self-study course.  While it isn't necessary to review these before our workshop, it will really put you ahead of the game and we focus more on procedures.

Custom Maquet Circuit

Figure 1. The Custom Maquet ECMO Circuit

Study Guide

Screen Shot 2015-04-04 at 11.04.36 PM

Review of the 3 stages of ECPR

  1. STAGE 1: Placement of any commercially available vascular catheter in the femoral vein and femoral artery
  2. STAGE 2: Replacement of each catheter with ECMO cannulae. Checkout EDECMO 5: Cognitive Task Management for ED ECMO Stages 1 and 2. Also, we learned several cannulation pearls from Stephen Bernard in EDECMO 14 Part 1 and Part 2
  3. STAGE 3: Initiation of Total Heart Lung Bypass

ECMO Circuit Setup:

  1. Plug in the machine and power-on the heater-cooler and the Rotaflow console.
  2. Unpackage the circuit and hold it up to orient yourself.
  3. Mounting the Rotaflow Pump to the Pump Drive

    Mounting the Rotaflow Pump to the Pump Drive

    Attach the Oxygenator to the bracket and the pump to the pump-drive; hang the distal ends of the circuit (the tubes that will connect to the patient) from the IV pole.

  4. Apply ultrasonic contact cream to the flow probe contact site
  5. Remove and DISCARD the yellow de-airing exit port cap on the top of the oxygenator.
  6. Connect the water lines from the heater-cooler to the Quadrox Oxygenator & open the stopcocks.
  7. “Run the circuit”, making sure that the recirculation bridge is OPEN, arterial and venous tubing is CLAMPED, rapid-prime tubes are CLAMPED, both of the blood sampling “pig tail” stopcocks are CLOSED.
  8. PRIME the circuit:  Priming the Circuit: Filling the ECMO circuit (tubing, pump, oxygenator) with crystalloid priming solution (ie Isolyte), adding 2,500 units of heparin to each 1-liter bag of priming solution.  We discuss the finer details of this with Greg Griffin, the Chief Perfusionist at the University of North Carolina, Chapel Hill in EDECMO 8.
    1. squeeze all air out of prime bag INTO the circuit and then hang those bags from the IV pole.
    2. Open the ratchet clamps: the circuit will fill (prime) by gravity.
  9. Connect the Oxygen supply line (from Oxygen tank) to the Oxygen inlet port on the oxygenator
  10. De-air the circuit:
    1. Remove the patient-lines that are hanging from the IV pole and drop them below the fluid level of the IV bags to prime them. ratchet-clamp them closed. Now the entire circuit has been primed.
    2. Open the recirculation bridge and briefly increase the RPM on the Rotaflow Console until the pump is running at 4LPM for 15 seconds. This will de-air the circuit as air is release from the de-ar exit port on the Oxygenator.  ***Some air may still be trapped in the pump though. So…
    3. Turn the RPM on the Rotaflow console to zero. Allow any air in the pump head to flow into the PVC tubing between the pump head and the oxygenator and then return the RPM to 4LPM to complete the de-airing process.
  11. Calibrate the flow-probe: Reduce pump speed to zero RPM, clamp off the recirculation bridge and “ZERO” the flow probe by pushing the “ZERO” button for a few seconds. The console will beep.

Initiation of Total Heart Lung Bypass (STAGE 3)

Maquet-Circuit-mockup.001So you've cannulated your patient while your ECMO-nurse has primed the circuit with crystalloid.  Connect the venous and arterial PVC lines from the circuit to the ECMO cannulas in the patient. And since this is STAGE 3, we've established the EDECMO “Rule of 3's.”  There are 3 things you need remember before, during, and after you've initiated heart-lung bypass.

A.  3 Critical First Steps BEFORE initiating bypass:

  1. Heparinize the patient = 5,000 units IV bolus
    1. Heparin 2,500 units in each liter of priming solution
    2. Bioline coating
    3. ACT > 200 seconds
  2. Attach O2 source (@ 4-6 LPM) to the Oxygenator
  3. No open central lines (CVP, Swan-Ganz, etc).

CLOSE the Recirculation Bridge and OPEN the venous and arterial ratchet clamps. Turn up the RPM on the Rotaflow console. Your patient is on heart-lung bypass.

B.  3 Critical things to confirm JUST AFTER your patient is on bypass:

  1. The arterial line should have bright red (oxygenated) blood and the venous line should be dark-red.
    1. IF you see BRIGHT-BRIGHT, you've incorrectly placed both cannulas in the same vessel.
    2. If you see DARK-DARK, there is a problem with the oxygenator. Confirm your O2 supply to the oxygenator.
  2. Your cannulas are secured to the skin with suture and tape.
  3. The recirculation bridge is CLOSED.

C.  3 Critical Values to Optimize ECMO

1. Optimize Blood Flow:

  • Establish the MAXIMUM blood flow (LPM) at the lowest RPM. GOAL = 60 ml/kg
  • Increase the RPM on the Rotaflow console until:
    1. Any further increases in RPM does not result in increased blood flow (LPM).
    2. The circuit begins to “Chatter.”
    3. SvO2 > 70%

IF flow is too low: 1. Infuse more volume 2. reposition venous cannula 3. add a venous cannula

2. Arterial Blood Gas Analysis:

  • GOAL:  “normal” ABG (PaO2 80-100; PaCO2 35-45)

IF PaO2 < 80,   THEN you need more blood flow through the Oxygenator

IF PaO2 > 100, THEN its time to add a gas blender and turn down the FiO2 from the Oxygen source

IF PaCO2 < 35, THEN decrease your “Sweep Gas Rate” by lowering the LPM on the O2 supply

IF PaCO2 > 45, THEN increase your “Sweep Gas Rate” by increasing the LPM on the O2 supply

 

3. Optimize Systemic Vascular Resistance (SVR)

SVR = (MAP – CVP) x 80
C.O.

SVR = (MAP – 0)      x 80
Blood Flow

***GOAL = SVR > 800

IF, for a given blood flow, the MAP is unreasonably low, you need a pure VASOPRESSOR = Phenylephrine

IF, for a given blood flow, the MAP is unreasonably HIGH, you need a VASODILATOR = Nitroprusside

Or, Goal MAP > 65

 

 The Shinar 3000: Tall Paul ECMO Simulator

Zack built an ECMO simulator model in his garage. Here is the video:

Tall Paul Compilation 3 from Joe Bellezzo on Vimeo.