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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.

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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.

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:

• 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.)

• 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:

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Who Gets ECPR and Who Doesn't?

Great question! This may be the hardest question we deal with when a patient arrives and ECPR is a consideration.

This episode is broken down into three parts:

1. Who exactly do we consider an appropriate candidate for ECPR?
2. TOR = Termination of Resuscitation in the pre-hospital arena and why we HATE it!
3. Pre-hospital ECPR – REALLY?

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In this episode, Joe and Zack discuss some of the terminology and basics of ECMO and ECLS.

Terminology: (Synonyms)

• ECMO = Extracorporeal Membrane Oxygenation
• ECLS = Extracorporeal Life Support
• CPS = Cardiopulmonary Support
• ECPR (extracorporeal cardiopulmonary resuscitation)=ECLS initiation in the arresting patient

ECPR candidates:

• STEMI with refractory VFIB
• PE with shock or dysrythmia
• Aortic Dissection
• Massive OD
• Pregnant with Amniotic fluid embolus
• Hypothermia with temperature-dependent dysrythmia
• Trauma

Future podcast episodes will drill down into the details of ECMO initiation, but in this episode Zack and Joe discuss Zack's recent case where Zack did it all: managed the code…placed the cannulas…and initiated bypass, right there in the Emergency Department.