EDECMO 22 – Managing the Crashing Tox Patient with ECMO – with Leon Gussow & Steve Aks from The Poison Review


…the key thing is to put them on ECMO when they need it, but not a minute sooner!

-Leon Gussow

In this episode Scott, Zack and Joe were all in the same room…in a conference room at the University of North Carolina, Chapel Hill – where we were doing ECPR studies in an animal model of cardiac arrest with Jim Manning. We spoke with legendary toxicologists Leon Gussow and Steve Aks about the role of ECMO and ECPR in the overdosed tox patient.

This is a fascinating discussion about the nuances of ECMO in the crashing intoxicated patient.

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GussowLeon Gussow MD,

University of Illinois Medical Center, Chicago
John H. Stroger Jr. Hospital of Cook County
Emergency Medicine News “Toxicology Rounds”
Medical Editor of ‘The Poison Review”



Director, Toxicology Fellowship Program, Department of Emergency Medicine, Cook County Health and Hospitals System


Some Unique Situations:

ECMO and intralipid?

  • What are the adverse effects associated with the combined use of intravenous lipid emulsion and extracorporeal membrane oxygenation in the poisoned patient. Clin Toxicol (Phila). 2015 Mar;53(3):145-50. doi: 10.3109/15563650.2015.1004582. Epub 2015 Jan 29.
  • Bolus dose intralipid before ECMO is reasonable and should not result in significant pump complications with our current oxygenators.  However, starting intra-lipid after the patient is on bypass won't likely provide much more benefit and could shorten the life of your oxygenator.

ECMO and Dialysis?

  • Hemodialysis can be done in-line with the ECMO circuit, but its preferred to use a separate dialysis catheter placed at a remote site (ie the IJ).  A dialysis circuit CAN be spliced into the ECMO circuit, but is a little more complicated.

Mitochondrial and Cellular Respiration Poisons (dinitrophenol & Cyanid) and Carbon Monoxide?

  • ECMO is of NO USE in these intoxications.
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[…] are joined on the ED ECMO podcast by Steve Aks and Leon Gussow to discuss the role of ECMO in the management of the crashing tox patient. […]

Joseph Bednarczyk
Joseph Bednarczyk
3 years ago

Interesting discussion regarding intralipid’s role with ecmo in cardiotoxic overdose. We have anecdotally found several patients developing severe delayed ARDS post lipid in these scenarios, in some case requiring conversion from VA to VV ecmo (after cardiac recovery). The differential is always broad (aspiration, cardiogenic edema, post msof etc), however, case reports of ARDS have been published following high dose lipid formulations given historically with TPN.

For this reason I currently consider a risk profile associated with intralipid, and fully agree with not administering it if patient is already established on VA.

Curious if any others have seen this…


[…] joined on the ED ECMO podcast by Steve Aks and Leon Gussow to discuss the role of ECMO in the management of the crashing tox patient. […]

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