The Death of Mechanical CPR (mCPR)? Hell No!

Bellezzo was a guest on R.E.B.E.L. EM's podcast episode 34.

Our friends, Salim Rezaie and Anand Swaminathan, do a bangup job of reviewing this recent article, published in December 2016, that suggests that mechanical CPR (mCPR) may be more harmful than manual chest compressions:

  1. Buckler DG et al. Association of Mechanical Cardiopulmonary Resuscitation Device Use With Cardiac Arrest Outcomes: A Population-Based Study Using the CARES Registry (Cardiac Arrest Registry to Enhance Survival). Circulation 2016; 134: 2131 – 2133. PMID: 2799402

Bellezzo showed up to kick the article in the nuts.

Check out the REBEL EM blog and podcast:

http://rebelem.com/episode-34-death-mechanical-cpr-mcpr/

EDECMO 17 – The Reanimateur: Lionel Lamhaut on Pre-Hospital ECPR

Lamhaut

Dr. Lionel Lamhaut

In this episode Zack sits down with Dr. Lionel Lamhaut, an anesthesiologist and “reanimateur” from Paris, France, about their pre-hospital ECMO program. Yes. You read that right. This group from France is  sending an ECMO team to the scene of the cardiac arrest and, in appropriate cases, initiating ECMO in the field.  Does this really work? What are the logistics of making this happen? Is this the future of pre-hospital resuscitation? Does this model translate to EMS models in other countries?  And most importantly, does this finally challenge the despicable “Termination of Resuscitation” (TOR) policies that have been metastasizing throughout our EMS communities?

The Plague of the TOR:

In the U.S. the “Termination of  Resuscitation” (TOR) policies are plaguing our pre-hospital colleagues. By TOR ideology, paramedics arrive to the scene of an arrested patient and work the patient until either ROSC or death.  This is the “stay and play” model at its extreme.  They simply don't transport patients to the hospital unless they achieve ROSC in the field.  No ROSC = No transport.  Dead.   We have become victims of our own success; Paramedics are now so good that they can do (almost) everything in the field that could be done at the hospital.  And, as the argument goes, transporting patients only results in: 1.) lesser-quality chest compressions, 2.) potential EMS/rescuer injury (by not being strapped into their safety harnesses during transport), 3.) inherent public dangers in transporting patients “Code 3” (lights and sirens), etc.  In other words, Emergency Departments traditionally couldn't offer anything that medics could not offer in the field and the quality and safety of the patient and the rescuers was worse because of the transport.

Well…that all changes with ECMO.  Here are the three current options:

  1. San Diego:  In our Emergency Department Emergency Physicians initiate ECMO.  We still suffer from the policies of TOR but try to encourage our EMS team to consider transport of certain patients.
  2. Australia (CHEER), rescuers initiate CPR with a mechanical chest compression device, begin intra-arrest cooling, and transport immediately to their ECMO/CPB center (The Alfred Hospital in Melbourne). For more on CHEER and the Alfred Hospital in Melbourne, Australia, check out Part 1 of our interview with Dr. Stephen Bernard on EDECMO Episode 14.  And Part 2 of our interview with Dr. Bernard was EDECMO Episode 15.
  3. France: Pre-Hospital ECMO.  Hell, the word “Reanimation” is painted right on the front of the ambulances in Paris!    This is what this episode of the EDECMO podcast is all about.

 

Mobile ICU = First responders

-physician on ambulance

-“Exactly like trauma room”

Prehospital ECMO Team

– 2 senior non-surgeon physicians with expertise in ECMO, 1 nurse, 1 paramedic

– Maquet™ Cardiohelp

– 2 units of packed RBCs and 2 units of FFP

– Sedation

– Therapeutic Hypothermia

Approach

– Seldinger technique with modified cutdown of proximal vessels. They FIRST do a cutdown to expose the femoral vessels. They then insert the needle DISTAL to the femoral cutdown and visualize direct vessel access within the open surgical field.  That way, the cannulas are actually placed percutaneous while vessel access can be directly visualized. Lionel says that this approach is actually faster and safer than just blindly stabbing around with the needle as is done with a blind percutaneous method. Hybrid seldinger

Inclusion Criteria

– Physician on scene makes assessment

– Positive bystander of CPR

– Younger people

– Shockable rhythm better

Ideology

– Out of hospital cardiac arrest survivorship should be the same as In-hospital cardiac arrest

– Need to decrease low flow state (shorten the time patients need chest compressions by getting them on the pump ASAP)

– 20 minutes to bypass in the field from arrival of prehospital ECMO team

– This gives you bypass of less than 60 minutes

– “Load and Go” is not fast enough

Results

– 10% survival from prehospital ECMO

– ECMO is a “Bridge to Neurologic Assessment”

– Organ Donation

Examples of Pre-hospital ECMO*

ECMO at the Louvre

ECMO at the Louvre

ECMO in the Supermarket

ECMO in the Supermarket

ECMO in the street

ECMO in the street

ECMO in the Subway

ECMO in the Subway

(*photos courtesy of Lionel Lamhaut)

Two Articles By Lamhaut:

Successful treatment of refractory cardiac arrest by emergency physicians using pre-hospital ECLS

Safety and feasibility of prehospital extra corporeal life support implementation by non-surgeons for out-of-hospital refractory cardiac arrest

Want More?

EDECMO 14: The CHEER Trial with Dr. Stephen Bernard

EDECMO 15: Part 2 of our interview with Dr. Stephen Bernard

INTENSIVE: The Alfred Hospital's amazing ECMO site