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]

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 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

 

REANIMATE 4 Tickets on Sale NOW!

REANIMATE 4: the World's premier endovascular resuscitation conference, held in San Diego California, is September 21-22, 2017. Join us for the most engaging immersion into the world of Extracoporeal Life Support, Extracorporeal CPR, REBOA, and hyper-invasive endovascular resuscitation teaching.

  • Registration: www.reanimateconference.com/register

Who:

The REANIMATE Core: Weingart, Shinar, Bellezzo, Ho

R4 Guest Faculty:

Steve Bernard (from The Alfred Hospital in Melbourne Australia, the ‘Bernard' Hypothermia trials, CHEER, ECPR), Zaf Qassim (REBOA specialist), Chris Muhr (TEE + ECHO specialist from Sweden), Jim Manning (endovascular resuscitation specialist & creator of the Selective Aortic Arch Perfusion Catheter – SAAP)

WHAT:

VA-ECMO, ECPR, Code Choreography, TEE/ECHO, endovascular resuscitation, VV-ECMO, mechanical CPR, vascular cutdown, REBOA.

  • tons of hands-on, practical, training and the opportunity to join the REANIMATE resuscitationist alumni team

WHERE:

San Diego, California.  The event is held at the UCSD Medical Education and Telemedicine building on the beautiful UCSD Medical School campus.  Didactic sessions are held in a beautiful state-of-the-art auditorium and practical hands-on simulation is done in the Center for the Future of Surgery: https://goo.gl/maps/jXUNBLcTih32

WHEN:  Sept 21-22, 2017

REGISTER:  www.reanimateconference.com/register

How to Build a REBOA Cannulation Model in 1000 Easy Steps!!!

How to build a REBOA Model is 1000 Easy Steps… from Joe Bellezzo on Vimeo.

 

Here is the video on how the REBOA models are built for #REANIMATE

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

2017 Das SMACC

Finally we now know what DasSMACC has in store!

Here are some inside tips that we have received from the SMACC organising committee that will help you prepare for the ticket release which is scheduled for Wednesday 8.00 am 26th October (Sydney Australian EST), or 22.00 London, 17.00 New York on the 25th of October for those on that side of the world.

das-smacc-tix-schedule-oct

Das SMACC Ticket Release

Delegate numbers are capped at approximately 2000 registrations again this year as we believe this is the best size to maintain our FOAM community atmosphere. In an attempt to be as fair as possible here are the basics of how it will work:

  1. Registration will open on Wednesday, 26th October at 0800 Sydney EST – click here for your local time.
  2. There will be 3 separate ticket releases: the major release will be as above on Wednesday, 26th October, a smaller allocation will be released on Wednesday, 7th December and a final limited release on Wednesday, 1st February
  3. Your best chance will be with the first release, but if you really need to wait until you have leave confirmed then you can chance your hand on the February release
  4. All prior delegates will receive an email reminder the week before tickets go on sale, but there is no other preference (first in best dressed!)
  5. Owing to the limited number of spots there will be no DAY ONLY registrations issue
  6. Workshop registration also opens on Wednesday, 26th October and like last year will be on a first come first served basis
  7. If you miss out on a ticket there will be a waiting list
  8. If you miss your preferred workshop there will also be a waiting list

What ’s in the program and registration at a glance for 2016?

We have taken all your feedback into consideration and planned for:

  • Another massive day of workshops on Monday, 26th June 2017 (WORKSHOPS)
  • A single stream format only featuring the best of the best (PROGRAM)!
  • The most incredible venue: the Tempodrom
  • Fabulous accommodation deals which are essential this year as Das SMACC is just before fashion week (ACCOMMODATION)
  • Registration details are here
  • The continued innovation and convenience of onsite childcare (crèche)
  • A bigger and better SMACC party. Yes, it will be massive.

Das SMACC – Berlin

The Social Media and Critical Care Conference continues to harness the immense energy of FOAM and dasSMACC in Berlin June 26-29 2017 promises to be the best one yet.

SMACC has seen spectacular growth since its humble beginnings. The Conference has grown from an enthusiastic idea into a global leader amongst critical care events. Whilst SMACC is primarily a high quality, academic meeting, the real reason behind this growth is the enormous and inspiring energy of the critical care community itself. A community that crosses traditional hierarchies, professional barriers and international borders. This is a community dedicated to innovation, teaching and learning. A community based around the pursuit of excellence in patient care, and a passion for sharing this as widely as possible.

What Makes SMACC Different?

So, why did the SMACC conference SELL OUT all 2000 delegate registrations in minutes?

To begin with, the affiliated websites supporting SMACC represent a comprehensive list of the “who’s who” in the FOAM world. The talented clinicians behind these websites have come together and harnessed their innovation, vitality and expertise to create the SMACC experience. The strong social media connections inherent to SMACC result in an ongoing, online conversation, which in turn, empowers the delegate and enhances their experience. SMACC is focused on being a conference truly for the delegates. Delegates have a say in every aspect of the meeting, including the speakers chosen, program topics, themes and styling, social events, and the questions asked in sessions. This level of delegate interaction with the conference is unparalleled in critical care.

There have also been many positive lessons learned from the FOAM world, which have now been translated into the SMACC Conference. Lessons on how to engage, inspire and make critical care education enjoyable. We keep the talks short (15-20 minutes), choose the topics carefully, handpick speakers who we know can both educate and inspire, and discourage reliance on power point presentations. Of course, all the sessions are recorded and podcast to be released in a FREE series – creating more great FOAM!

But SMACC isn’t just about the academic presentations. SMACC is an experience. The opening ceremony, the themes of the exhibition hall and welcome events, the teas and lunches provided in the breaks and the massive Gala night, all of which are included in the one registration price, are designed to bring the group together and enhance the feeling of belonging to one critical care
community.

Why Berlin?

Berlin is an amazing and vibrant city and has the energy capable of hosting SMACC. It is no surprise that it has become the artists’ capital of Europe. There is an intriguing combination of grittiness, openness, willingness and enthusiasm in the Berlin community, which make it a perfect destination for the FOAM community. Of course that’s to say nothing of the history, museums and bars.

Berlin is also perfectly situated in the heart of Europe to springboard any European adventure.

1 min VIDEO DAS SMACC Oct Tix Promo 2 from Joe Bellezzo on Vimeo.

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

NEW ED ECMO Article from the ERECT Collaborative is in Press:

download

Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO)

Joseph E. Tonna,∗, Nicholas J. Johnson, John Greenwood, David F. Gaieskie, Zachary Shinar, Joseph M. Bellezzo, Lance Becker, Atman P. Shah, Scott T. Youngquist, Michael P. Mallin, James Franklin Fair III , Kyle J. Gunnerson, Cindy Weng, Stephen McKellar, for the Extracorporeal REsuscitation ConsorTium (ERECT) Research Group