Episode 4 – The Tactical Approach to the Cardiac Arrest

In this episode we talk about how we prepare for, and run, our codes.  When we began incorporating ECPR into our resuscitation strategy we found ourselves saving patients who would have otherwise died.  The traditional nihilistic approach to the arresting patient was overturned with ECPR by providing hope that wasn’t previously there. Naturally,  we took a closer look at each element of the code, from the time the patient hit the door to the time we started the pump.  And we realized we were doing a lot of stuff wrong.  Here is how I do it:

1.  Medic gurney entry:    If you’re doing ECPR, then vascular access of the femoral vessels is a top priority. Most of us are right handed and prefer to access the femoral vasculature on the patient’s right.  But that’s EXACTLY where the medic gurney offloads the patient- big mistake. Time is wasted waiting for the medics to move the patient to your hospital gurney, remove monitor leads, pack up the monitor, avoid pulling out IV’s and then leave the room.  Only then could the “line doctor” push the ultrasound machine into the room, disrobe the patient, gown up, place a sterile US probe cover, prep the field and get to work.  That’s precious minutes wasted.  Stop doing that!  Bring the medic gurney in on the other side!  Your “line doctor” is already completely ready to go.

2. Protocolize EVERYTHING:  ACLS provides  a protocolized framework for running a code.  But what about all that stuff that happens from the ambulance bay until care is transferred to you?  And can we improve on the current ACLS algorithm?  Most of us appreciate that protocoling doesn’t restrict us; in fact, quite the opposite.  A protocol allows cognitive offloading of important, yet routine, steps in a process which frees us to focus on tasks specific to that patient.

If you are considering establishing an ED ECMO or ECPR program at your facility, I highly recommend that you take a close look at everything that is done from the time the patient hits your door to the time the ECLS pump is started. We aren’t saying this is the only way to do it, but this is how we do it:

Anticipating the Arrival of an Arresting Patient:

  • Staging the room: not unlike a theatrical play, each person and each piece of equipment has a specific role and a specific position in resuscitation suite.  Do it the same way every single time.Slide1

 

resusc room 2014

Accepting the CPR patient on the “RIGHT Side!”

Some roles that are unique to our resuscitation team:

  • “Line Doctor”: MD responsible for femoral vascular access
  • “Code Doctor”: MD responsible for running the code and decision-making
  • “Code Team Leader”: RN responsible for timing of important events (ie drug delivery, shocking, pulse checks, etc). This RN also does computer-based charting.
  • “Med/Electric Nurse”: RN responsible for pushing drugs and delivering shocks
  • “Resuscitation Cart”: lives just outside the room and has two shelves and house the following:

Resuscitation Cart

  • Quiet the room: as the medics enter the room, quickly remind everyone to limit unnecessary noise.

Patient Arrival:

  • The paramedic gurney (with ongoing CPR) enters the room on the right side of the room (if you are looking from outside to inside the room), not the left (which is how you are likely accepting your patients now.)

Slide2

 

  • After transfer of the patient from the medic gurney to the ED bed, chest compressions are immediately assumed by “Chest compressor #1”.  compressions then move back and forth between the two “Chest compressors” at pulse checks.
  • Since femoral vascular access is a huge focus, I would also recommend that you assign a free hand (RN or tech) to “groin access,” who is standing outside the room with trauma shears in one hand a bottle of betadine in the other.  Once the patient is moved from the medic gurney to the ED Bed, that individual is tasked with stripping the pants off (by cutting or pulling) and drenching the groins in betadine.  It becomes an efficient task for the “line doc” to drop a drape, place the US probe, and gain femoral vascular access.
  • Of course, the need for both of these human chest compressors (and valuable real estate in the resuscitation room) is eliminated if you have a mechanical chest compression device such as the LUCAS2:

LUCAS2

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6 Comments on "Episode 4 – The Tactical Approach to the Cardiac Arrest"

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Thomas D
Guest
Great episode! These logistics and small tips are so important, and when I think of it, this tactical stuff is important for all/any medical interventions. And you never learn or read them anywhere, but you experience them after starting to work as a doc. Learning the tactics of doctoring early on might make for better junior docs. Or, like here, helping already experienced docs doing new things like ECPR better from the get go, instead of repeating all the challenges you probably faced when starting your ECPR program. Anyway, this episode made me think, and become much more aware of… Read more »
Thomas
Guest
Hi ED-ECMO, love your show. very importent stuff. In our shop we have just started a ECPR program and have to date put 5 patients on the pump. Our setup is a little bit different: we accept our patients (on LUCAS2) in the cathlab with a interventional cardiologist as teamleader. We do the usual cannulation as for PCI and do a “quick and dirty” coronary angiography to deal with an obvious occlution. If the patient doesnot regain ROSC we (the cardiologist with a thorasic surgeon) continue the cannulation and procede to VA ECMO. If the PCI takes to long time… Read more »
Rob Martin
Guest
Hi Joe. Love the set up and approach with only one slight difference. I am in EMS and use the Stryker Power Pro stretcher. It is equipped with a rack to support our LP15. It is attached just below the patients right knee. Attempting to transfer from the right as you suggest is problematic. I have been delivering more patients to the ED in a ROSC state and am using the post arrest hypothermia guidelines set forth by Sunnybrook Base Hospital in Toronto, Ontario. Having IV’s established and the other monitoring devices including 12 lead, I find the transition in… Read more »
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