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“Let me tell you, PEA is just a bunch of bullshit.” -Joe Bellezo aka @edecmo http://t.co/2cFCjizhYe

— Rob Orman (@emergencypdx) November 13, 2014

This is the first episode where all three of the EDECMO boys are together–yeah! Today we talk about a bunch of PEA stuff. Scott proposes 2 new terms to bring us into the modern era: PREM-pulseless with a rhythm and echocardiographic motion PRES-pulseless with a rhythm and echocardiographic standstill Joe asks why we shouldn't just treat the latter like asystole, and he's probably right. But what of the former? What should we do with that? Listen to the episode.  

Jim Manning's talk at GSA HEMS

On Youtube

Here's the Littmann Article on PEA

A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity

Update

Our friend Gregor Posen performed this excellent Pseudo-PEA (PREM) Paper

 Bibliography

In this episode, Joe was “Orating via the Anus” while Zack and Scott took a more evidence-based approach:

• Larabee, T. M., et al. (2008). “A swine model of pseudo-pulseless electrical activity induced by partial asphyxiation.” Resuscitation 78(2): 196-199
• Paradis, N. A., et al. (2012). “Coronary perfusion pressure during external chest compression in pseudo-EMD, comparison of systolic versus diastolic synchronization.” Resuscitation 83(10): 1287-1291.
• Prosen, G., et al. (2010). “Impact of modified treatment in echocardiographically confirmed pseudo-pulseless electrical activity in out-of-hospital cardiac arrest patients with constant end-tidal carbon dioxide pressure during compression pauses.” J Int Med Res 38(4): 1458-1467
• Paradis, N. A., et al. (1992). “Aortic pressure during human cardiac arrest. Identification of pseudo-electromechanical dissociation.” Chest 101(1): 123-128.
• A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity

Update

This new study seems to demonstrate that stratification by ecg width may not be evidence-based

TrackBacks

“PEA is just a bunch of BULLSHIT!”  Joe talks about the FALLACY OF PEA on the ER Cast podcast with Rob Orman…  

How we're taught to manage PEA is BS. Here's a way that makes sense http://t.co/o8KUtblRA8 @edecmo joins ERcast to stop the madness — Rob Orman (@emergencypdx) November 29, 2014

Podcast: Play in new window | Download (Duration: 35:20 — 32.4MB)

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Paris ECMO Course

The excellent lecturer was Dr. Guillaume Lebreton,

Associate Professor and Cardiothoracic Surgeon
Director of the CPB and ECMO program,
Department of Cardio-Thoracic Surgery
Pitié Salpêtrière Hospital

How Not to Frack Up

• DO NOT ADAPT TECHNIQUE TO YOUR CAPACITY
• Fixed Point for Wire–meaning wire must be held stationary as you dilate, otherwise dilator will back wall through vessel with anything but the stiffest guidewire. We get a false sense of security from smaller line placement.
• Discussed being fooled by echo
• They do cutdowns for all ECPR

Inflow

• Crap flow if too small
• If you measure from the puncture site directly to the middle of the sternum, that should be your insertion. Too deep is better, with Maquet you want the tip in the RA
• 24-29 F with 25 being the sweet spot
• 55 cm Maquet for all adults
• When the holes are through the vessel, PULL Back the Dilator

Outflow

• Hemolysis if too small
• 17-21 F for VA
• 19-23 F for VV
• IJ catheter length-15 cm on right, 23 cm on left
• Don't pull back dilator for arterial placement

Placement

• Pad behind buttocks to straighten vessels 4″ or so
• Needle bevel facing up and wire's j facing up
• Gentle Angle for  Needle Placement
• Guidewire-go fast and it goes straight
• Always use the 150 cm guidewire. Leave 1 meter out, 50 cm in pt
• Scalpel-1 cm cut and plunge
• Doesn't bother rotating the dilators
• VV-do the femoral first as it is harder to knock out

Femoral-Femoral VV

• Return close to tricuspid, not multi-stage
• Drainage as central as possible, but in IVC, not RA
• Put in both guidewires first
• Put the longer cannula (return) in first
• Inflow-21-23 short insertion, but same length cannula (Maquet)
• Outflow-17-19, single stage (Medtronic)

TroubleShooting

• If at the same speed, decreased flow–think thrombosis

Starting VVECMO

1. Clamp on tubing
2. Start slow, 2000 rpm then slowly declamp
3. Start sweep at 6 lpm (or 1:1 with flow)
4. Go up to the max flow you can get at first to see your max
5. You want to provoke reflow
6. You should be able to get big flows (6-7 lpm)
7. Dial Back to 5-6 Liters or 3 L/m2 (>60% of CO is what you should be aiming to capture)
8. You should be able to get to 100% sat quickly
9. If you are seeing recirc, pull back inflow slightly (max 1-3 cm)

• Treat the pt not the xray when it comes to cannula positioning

Factors that increase Recirc

• Proximate venous tips
• Low CO
• Hypovolemia
• Increased pump flow rates

Avalon

Turn Head all the way to the left to align IVC and SVC

VA

FEM/FEM
do venous 1st if doing cutdown

Image by Cedric Lange

Podcast: Play in new window | Download (Duration: 31:16 — 28.7MB)

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Joe and I discuss ECPR cannulae placement from a cognitive task analysis (sort of) perspective. Beware: agonizing detail follows.

I believe this episode may help you even if you never do ECMO, as it is directly applicable to large central line placement as well.