EDECMO 25.5 – (Part 2) an EDECMO short with Jim Manning – on location with the SAMU pre-hospital ECMO team in France

In followup to our discussion with Jim Manning MD (@JManning_UNC)  and Lionel Lamhaut (@LionelLamhaut) MD of the Service d’Aide Médicale Urgente (SAMU) for EDECMO Episode 25, the guys spent the last few days ‘just hanging out in Paris.”

The recent massacre in Paris certainly makes this topic..well…topical.

Manning spent several days with the prehospital ECMO team in France.  In this episode Zack interviewed Manning, who was on-location with the SAMU in France…and walks us through the experience of witnessing prehospital ECMO with the SAMU.

In the U.S., we aren’t yet ready for pre-hospital endovascular resuscitation – indeed there are currently several barriers to overcome. But perhaps the Europeans are onto something here:

Femoral cutdown vs. percutaneous access? Discussed. Verdict?

Transporting a patient on ECMO:

You know, the thing is…that once you have a patient on ECMO, everything chills out…

-Jim Manning

Every patient gets:

  • Dobutamine: 5 ug/kg/min
  • Norepinephrine 3 mg/hr
  • pRBC 2 units
  • FFP 2 units

Flow goals: start 2.5-3 lpm…then slowly increase. Does this help quell reperfusion injury?

This is the exciting. This is fantastic. This is the future if you ask me. We are going to be doing this and its just a matter of time before the rest of us realize that…we are headed in the right direction

Jim Manning

Jim Manning

SAMU Ambulance

SAMU Ambulance

Lionel Lamhaut and the SAMU ambulance

Lionel Lamhaut and the SAMU ambulance

Manning & SAMU

Manning & SAMU

EDECMO 25 – ‘Ze ECMO TEAM.’ Manning and Lamhaut: Updates on ECMO, the new 7F REBOA Catheter, and Pre-hospital ECMO in France

In this episode, Zack interviews Jim Manning MD (University of North Carolina) and Dr. Lionel Lamhaut of the famed French SAMU (Service d’Aide Médicale Urgente).

Highlights:

2015 Resuscitation Science Symposium updates:

“ECMO is at the forefront of resuscitation science” – Jim Manning

The New REBOA Catheter: Pryor Medical – just obtained FDA approval for endovascular proximal control of non-compressible hemorrhage below the diaphragm.

At Sharp Memorial Hospital we currently use the 12Fr Chek-Flo sheath, paired with 12F (external diameter) CODA balloon occlusion catheter for non-compressible hemorrhage below the diaphragm.  Pryor Medical has just gained FDA approval to market their REBOA catheter – a 7F version that doesn’t seem to require surgical repair of the arteriotomy site.  For those of us doing REBOA, this is a BIG DEAL:

Website Image 10-26-15

Selective Aortic Arch Perfusion Catheter (SAAP) – which is like a REBOA catheter but has a lumen large enough to perfuse blood (or a blood substitute) through.  Manning talks about what’s sexy with his device.

 

Lionel Lamhaut from the French SAMU (Service d’Aide Médicale Urgente) gives us an update on their prehospital ECMO program in France:

SAMU Inclusion Criteria:

  1. Medical Cardiac Arrest
  2. Age < 75
  3. No Flow < 5 min (bystander CPR must be started within 5 min)
  4. Hypothermia is always considered
  5. Intoxications (of any kind) are always considered
  6. ETCO2 > 10

For review, check out our original discussion with ‘reanimateur’ Dr. Lamhaut about prehospital ECMO: edecmo.org/17

In keeping with all of the in-hospital and out-of-hospital ECPR data accumulating, it appears that Lamhaut’s team is also seeing a success rate (survival with CPC 1 or 2) of around 30% (final data pending publication).

 

Consider this: the modified cut-down technique. The French prehospital team, quite obviously, don’t have ultrasound access in the field.  So instead of using ultrasound visualization of the femoral vessels, they necessarily use direct visualization.  Listen to this episode to hear the details…

 

 

 

 

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