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:

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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

EDECMO 29 – ECMO in Hypothermic Cardiac Arrest – with Torvind Naesheim of Norway

Torvind Næsheim

 

 

University of North Norway, Tromso

University of North Norway, Tromso

University Hospital of North Norway:

  • located at 69 degrees North latitude – likely the northernmost ECMO center in the world.
  • The warmest month is July with a mean air temperature of 11.8C and mean sea temperature of 10.8 C.
  • The coldest month is January with a mean air temperature of -4.4 C and mean sea temperature of 5.1 C.
  • ECMO program since 1988
  • Yearly ECMO volume is approx 20 per year – including postcardiotomy support, ECPR, cardiogenic shock and respiratory failure
  • ECMO Retrieval Ambulance service: Since 12/2015: 5 ECMO transports
  • Cases are reported through the ELSO registry

Accidental Hypothermia – some definitions:
mild : 32-35 C – preserved capability to maintain core temperature through compensating thermoregulatory mechanisms
Moderate: 28-32 – loss of ability to sustain temperature via either voluntary or autonomic means
Severe: 20-28 – high risk of malignant arrhythmias
Profound: <20 Asystole

The Paper: Hilmo, J et al. Prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas – A retrospective study from northern Norway. Resuscitation , Volume 85 , Issue 9 , 1204 – 1211

  • “Nobody is dead until warm and dead”
  • retrospective study looking at accidental hypothermia victims with cardiac arrest admitted to UNN between 1985-2013
  • no survivors prior to 1999
  • 1999-2013: 9/24 (37.5%) survival, defined as alive at 1 year – most with a ‘favorable’ neurologic outcome
  • PRIOR studies suggested that asphyxiation, either via snow burial (avalance) or water submersion had a lower chance of survival, but this study suggests that hypothermic arrest during submersion injury may be very different. It is hypothesized that very cold temps create faster cooling rates and aspiration of cold water may induce rapid protective cerebral hypothermia. So drowning victims (asphyxia by submersion in cold water may have a higher survival)
  • Hyperkalemia is bad (>8 is bad; >12 is dead)
  • Bottom Line: “No patient is dead until they are warm and dead” – current neuroprognostication can’t identify OHCA patients who may be salvageable.  So assume they are!

Key ECMO Points:

  1. Profoundly hypothermic patients cannot generate high flow rates – possibly due to increase blood viscosity.  Consider larger cannulae. Torvinde uses 29F venous and 21F arterial as a starting point.
  2. Rewarm with a veno-arterial temperature gradient of no more than 10 degrees C. Faster rewarming may result in bubble formation. Torvinde does this via the water bath heater/cooler.
  3. Therapeutic hypothermia is still in play. Torvinde holds the core temp at 36 for 24-28 hours.
  4. “You’re not dead unless you’re warm and dead” – consider transporting potentially salvageable patients with a reliable history.

Torvind and AnnaThe Story of Anna Bågenholm was told in this article in the Lancet:

Torvinde

 

 

 

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

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

3433685E-8535-4A3A-B5F2-001738A76FB4

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