EDECMO 40: EROCA – The trial that asks “Should ER Docs Initiate ECPR?”

 

EROCA – University of Michigan – Gunnerson/Shinar

Should Emergency Physicians initiate ECMO on arresting patients?  That is the question that Kyle Gunnerson from the University of Michigan (UMich) is asking with their new trial – EROCA.  UMich has had a robust ECMO program for over 30 years and recently they have received a grant to fund an out of hospital cardiac arrest protocol for emergency physician initiated ECPR.  In this episode, Zack asks Kyle how this trial is being undertaken with key side points on how to start a program, how to train the personnel, and how to circumnavigate the many roadblocks we commonly face in the development of an ECMO program.  They talk about the limitations of running a trial with physicians with no prior experience in ECPR initiation as well as the novel resuscitation strategies that UMich is deploying in all of their cardiac arrest patients.

 

EDECMO 39: Who Do We Put On ECMO? – New Data on Prognostics

In this episode Zack interviews the first authors of the three biggest papers this year dealing with the question of “Who should I put on ECMO?”  Guillaume Debaty of Grenoble, France published a paper outlining what prognostic factors are important.  Guillaume's data shows importance of short low times, lower lactates and higher pH values.  The real question is what number for each of these should we consider a hard stop on initiation.  This is followed up by Josh Reynolds who along with Ben Singer out of the UK published a paper utilizing cardiac arrest data from the PRIMED trial.  He showed that even patients with all the advantageous characteristics of traditional ECMO inclusion criteria had poor survivals once they have had >30 minutes of chest compressions.  With many ECMO studies having average arrest to

initiation times of > 60 minutes, Josh’s paper certainly makes us view favorably the 30% survival outcomes that we are seeing worldwide.  This in no way substitutes for a randomized trial but does offer some guidance on what the expected survival of a patient with a witnessed arrest, short low flow times, and age < 65.   We  conclude with Nate Haas out of the University of Michigan who utilitzed the ELSO database to show that age was not predictive of survival.  This may push us towards including older patients in our inclusion criteria, but more data is definitely needed on this.

 

Bibliography:

1: Haas NL, Coute RA, Hsu CH, Cranford JA, Neumar RW. Descriptive analysis of
extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac
arrest-An ELSO registry study
. Resuscitation. 2017 Oct;119:56-62. doi:
10.1016/j.resuscitation.2017.08.003. Epub 2017 Aug 5. PubMed PMID: 1.

 

2: Reynolds JC, Grunau BE, Elmer J, Rittenberger JC, Sawyer KN, Kurz MC, Singer
B, Proudfoot A, Callaway CW. Prevalence, natural history, and time-dependent
outcomes of a multi-center North American cohort of out-of-hospital cardiac
arrest extracorporeal CPR candidates. Resuscitation. 2017 Aug;117:24-31. doi:
10.1016/j.resuscitation.2017.05.024. Epub 2017 May 25. PubMed PMID: 2.

 

3: Debaty G, Babaz V, Durand M, Gaide-Chevronnay L, Fournel E, Blancher M,
Bouvaist H, Chavanon O, Maignan M, Bouzat P, Albaladejo P, Labarère J. Prognostic
factors for extracorporeal cardiopulmonary resuscitation recipients following
out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis.
Resuscitation. 2017 Mar;112:1-10. doi: 10.1016/j.resuscitation.2016.12.011. Epub
2016 Dec 19. Review. PubMed PMID: 3.

References

1.
Haas N, Coute R, Hsu C, Cranford J, Neumar R. Descriptive analysis of extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest-An ELSO registry study
. Resuscitation. 2017;119:56-62. [PubMed]
2.
Reynolds J, Grunau B, Elmer J, et al. Prevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates. Resuscitation. 2017;117:24-31. [PubMed]
3.
Debaty G, Babaz V, Durand M, et al. Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis. Resuscitation. 2017;112:1-10. [PubMed]

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]

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.

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!

EDECMO 35 – REBOA REVISITED!

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is used to gain proximal control over non-compressible hemorrhage below the diaphragm.  The concept has been covered extensively in social media.

Weingart did a wonderful job describing REBOA using the 12F Chek-Flo and CODA catheter here:

EMCrit Podcast 121 – REBOA

Our good friend Rob Orman from ERCAST.org and EMRAP interviewed Zaf Qasim:

REBOA 101

And Weingart revisited REBOA, spoke with Joe DuBose, and described the newest REBOA catheter, the PryTime 7F ER REBOA catheter that most of us now use:

Podcast 170 – the ER REBOA Catheter with Joe DuBose

 

…So we aren't going to rehash any of that stuff in this episode!

In this episode, Zack takes a deep dive into REBOA implementation, physiology, and complications with four of the biggest movers in the world of REBOA:

Dr. David Callaway Military Trauma Specialist

Dr. David Callaway is an Emergency Physician from the Carolinas Health System, who also serves on the Defense Health Board Subcommittee on Trauma and Injury as well as the Committee on Tactical Combat Casualty Care- two of the key U.S. advisory bodies for battlefield trauma care. He is the Co- Chairman of the Committee for Tactical Emergency Casualty Care, a best practices R&D group charged with translating battlefield lessons learned to civilian high threat prehospital medicine.

Dr. Callaway describes how they implement REBOA  in their busy trauma unit and some of the data behind its use.


 

Dr. Tatuya Norii University of New Mexico

But REBOA is not without controversy.  So Zack turned to Dr. Tatsuyo Norii, from the University of New Mexico, who published a study that showed that REBOA may result in increased mortality in certain patients.1 Dr. Norii believes that we should avoid REBOA in patients with traumatic brain injury and patients with multi-system trauma.

Shinar and Dr. Norii also discussed how REBOA may also be considered  non-trauma situations where patients are bleeding to death:  ruptured ectopic pregnancy, postpartum hemorrhage, ruptured abdominal aneurysm, and perhaps some patients with hemorrhagic gastrointestinal bleeding.

 


Austin Johnson MD PhD UC Davis

Then,  Zack turned to Dr. Austin Johnson from UC Davis.  They do  a deep dive into the physiology of of a patient on REBOA and its nuances in traumatic brain injury.

And lastly, They discussed the concept of partial REBOA (P-REBOA) and the concept of “windsocking”. As the balloon size is decreased by decreasing the volumes within it, the flow around the balloon is not linear. This becomes increasingly important as we consider ‘partial REBOA', prolonged occlusion, and balloon takedown, a topic published by Dr. Johnson a few months ago.2

 


Zaf Qasim MD REBOA guru

Finally, we wrap things up with a discussion with Zaf Qasim, REBOA guru who teaches the REBOA modules at our endovascular resuscitation conference, REANIMATE.

Do you want to learn how to aggressively manage the crashing trauma and medical patients using ECMO, ECPR, REBOA, ultrasound  and advanced resuscitation techniques?

 

REANIMATE 4 is September 21-22, 2017:

Register for REANIMATE 4

References

1.
Norii T, Crandall C, Terasaka Y. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg. 2015;78(4):721-728. [PubMed]
2.
Johnson M, Neff L, Williams T, DuBose J, EVAC S. Partial resuscitative balloon occlusion of the aorta (P-REBOA): Clinical technique and rationale. J Trauma Acute Care Surg. 2016;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S133-S137. [PubMed]

EDECMO 34 – The Day After REANIMATE – with Dr. Sean Deitch

In this episode, Joe talks with Dr. Sean Deitch, a non-academic Emergency Physician practicing in San Diego, California.  Dr. Deitch attended REANIMATE 3 – which just finished 2 weeks ago…and has an amazing story to tell.  You'll have to listen to the episode…

REANIMATE 4 is September 21-22, 2017 and features guest faculty member Stephen Bernard – coming all the way from Melbourne, Australia – and best know from the original therapeutic hypothermia trials and CHEER.  R3 was amazing and R4 will be even better!!

To register for REANIMATE 4: www.reanimateconference.com/register

 

EDECMO 33a – “Bringing Down the House” by Zack Shinar (from RESUSfest 2016)

In this episode of the EDECMO podcast, Zack describes how to use the concept of ‘TEAM PLAY”, much like the gang from the classic novel “Bringing Down the House” by Ben Mezrich, to optimize outcomes after cardiac arrest….with, or without, ECPR.

Zack's tips for running a code:

  1. Proper, high-quality CPR
  2. The choreography of running a code
  3. Let your nurses run the code
  4. CPR Alfresco (transitioning the patient from EMS gurney to hospital gurney IN THE AMBULANCE BAY)

Upcoming EVENTS:

REANIMATE 3 Conference: March 2-3, 2017 (sold out! but click the link to go to the wait list)

REANIMATE 4 Conference: September 21-22, 2017  (registration will open on March 21, 2017. Add your name to the REANIMATE wait list for first chance at R4 tickets)

Castlefest 2017: April 10-14, 2017

Resusfest 2017: April 13-14, 2017

Essentials of Emergency Medicine 2017 at the Cosmopolitan Hotel in Las Vegas, Nevada: May 16-18, 2017

 

Bringing Down the House:

 

EDECMO 32 – Archimedes Screw: Is Impella the Future of Mechanical Circulatory Support?

In this episode we change direction a bit and explore two very different applications of the Impella® device – a percutaneously-placed temporary ventricular assist device (VAD) sold by Abiomed (no financial disclosures). These VADs work by the use of a micro-axillary pump which is typically placed by interventional cardiologists under fluoroscopy. The inlet of the pump is placed in the ventrical while the outlet rests just above the aortic valve.  Take a look at this video for a  better understanding of how this works:

Guests on this show:

portrait-holst-jenelle-ann

Jenelle Badulak MD Critical Care Fellow University of Washington

vase

Dr. Henrik Vase Interventional Cardiologist Aarhus University Hospital, Denmark

 

 

EB Compton's/Archimedes screw/harchmd001a4 465 x 331/ cmccabe/09/28/2009

EDECMO 31 – Anaphylaxis & Epi-Pens. Are we ready for VV-ECMO in the Emergency Department?

Is There EVER a Role for Veno-Venous ECMO (VV-ECMO) in the Emergency Department?

Here is a case of a young man who presented to our Emergency Department in June, 2106 with profound anaphylaxis. This was a rare “CAN Intubate/CAN'T VENTILATE” scenario:

  1. Max Epinephrine
  2. Max antihistamines
  3. Max steroids
  4. Max ventilator

…and you still cannot ventilate.  PaCO2 is going up. pH is going down.

What options do you have? Find out in this episode.

 

Here is the video produced by Sharp Memorial Hospital (@SharpHealthcare) about this case:


Special thanks to:

Kevin Shaw MD Intensive Care Sharp Memorial Hospital

Kevin Shaw MD
Intensive Care
Sharp Memorial Hospital

Andrew Eads MD Emergency Medicine Sharp Memorial Hospital

Andrew Eads MD
Emergency Medicine
Sharp Memorial Hospital

Melissa Brunsvold MD Department of Surgery University of Minnesota

Melissa Brunsvold MD
Department of Surgery
University of Minnesota

Conrad Soriano

Conrad Soriano

Brynn Shinar Cutest Girl on Earth

Brynn Shinar
Cutest Girl on Earth