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. ┬áPaCO2 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

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

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Phillip Mason
Guest
Very nice save, gentlemen. Plenty of our colleagues in medicine view ECMO as a therapy limited to CT surgery or a small group of intensivists. With you guys continuing to push the ED ECMO envelope I am certain this will change. I would like to share some thoughts on your approach to VV ECMO, specifically the decision to place an Avalon cannula under emergency circumstances without real time imaging. While I am aware of only one published case report of RV perforation during Avalon placement (Hirose H, Yamane K, Marhefka G, Cavarocchi N. Right ventricular rupture and tamponade caused by… Read more »
EMCrit
Admin

Phil-
Amazing to have you here reading/listening to the edecmo stuff. Ever care to come on the show?
–Scott

Kevin
Guest

Agreed. Your precautions are right on, as is Joe’s explanation. This patient has unusual anatomy with very thick, leathery skin in the groin. After ECMO initiation, I did end up placing femoral arterial and venous lines for access, and had a tremendous amount of difficulty despite a very nice ultrasound machine.

With the retrospectascope in use, my approach would have been different. At the time, I had no ability to use TEE or fluoroscopy. If in the exact same circumstance again, I would recommend serial CXR with ultrasound of the IVC.

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