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. ┬áPaCO2 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

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tom fieroEMCritKevinjoebellezzoPhillip Mason Recent comment authors
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Phillip Mason
Phillip Mason

Very nice save, gentlemen. Plenty of our colleagues in medicine view ECMO as a therapy limited to CT surgery or a small group of intensivists. With you guys continuing to push the ED ECMO envelope I am certain this will change. I would like to share some thoughts on your approach to VV ECMO, specifically the decision to place an Avalon cannula under emergency circumstances without real time imaging. While I am aware of only one published case report of RV perforation during Avalon placement (Hirose H, Yamane K, Marhefka G, Cavarocchi N. Right ventricular rupture and tamponade caused by… Read more »


Phillip, (disclaimer: we have obtained full release from this patient to discuss his medical information freely, in the interest of education) You make excellent points. Zack and I presented this case to raise some awareness and availability of this salvage therapy… and to start this discussion exactly. I agree with all of your points and agree that “blind” Avalon placement is a risky move. I said it in the podcast episode: I don’t look forward to the day that this is my only option. But it may have been Dr. Shaw’s only option here. I spoke with Dr. Shaw about… Read more »


Amazing to have you here reading/listening to the edecmo stuff. Ever care to come on the show?


Agreed. Your precautions are right on, as is Joe’s explanation. This patient has unusual anatomy with very thick, leathery skin in the groin. After ECMO initiation, I did end up placing femoral arterial and venous lines for access, and had a tremendous amount of difficulty despite a very nice ultrasound machine.

With the retrospectascope in use, my approach would have been different. At the time, I had no ability to use TEE or fluoroscopy. If in the exact same circumstance again, I would recommend serial CXR with ultrasound of the IVC.

tom fiero
tom fiero

Zack and Joe, another cool pod. Dr Brusvold considers VV ECMO for anyone with ARDS, prone, FiO2 100%, PaO2 120… which if i recall is how much of this took off in australia with H1N1 epidemic 2009(?). a still another truly incredible pod, Z and J. conrad now has two birthdays. great description/presentation, work Dr Shaw. (and the team). question for Joe and Zack, then: if a conrad (purely pulmonary failure with good heart) came into your ER, would you do VV or VA? if VV, how ? north/south? Avalon? does anyone ever do right fem vein , left fem… Read more »

tom fiero
tom fiero

so sorry.

just read all the comments below, which more than answer my questions. (i think). still wonder if VV fem/fem wouldn’t just steal all the good blood just returned. i guess you’d need to place the tip of the cannula removing the blood several cm’s away from the tip of the cannula returning , but which more distal? i suspect the returning port should be more proximal, since you would want the returning blood closer to vital organs (?).