ED ECMO https://edecmo.org Resuscitationist-Initiated Extracorporeal Life Support Sun, 25 Oct 2020 23:34:23 +0000 en-US hourly 1 https://wordpress.org/?v=5.5.3 the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean episodic the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart edecmo@gmail.com edecmo@gmail.com (the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart) EDECMO 2013 Resuscitative ECMO, ECLS, and ECPR ED ECMO https://edecmo.org/wp-content/uploads/powerpress/edecmo-art-individual-podcast.jpg https://edecmo.org 67: Da DO2: Fundamental ECMO Physiology with Sage Whitmore https://edecmo.org/67-da-do2-fundamental-ecmo-physiology-with-sage-whitmore/ Wed, 14 Oct 2020 07:36:54 +0000 https://edecmo.org/?p=5975 Have you ever wondered about how initiating ECMO changes the cardiovascular physiology?  Have you wondered what metrics you should be looking at when resuscitating a patient that has a beating heart and a ECMO flow?  Dr. Sage Whitmore, an ED Intensivist from Nashville with ECMO training from UMichigan, leads us through the basic to the tough questions of ECMO physiology.  Zack Shinar Have you ever wondered about how initiating ECMO changes the cardiovascular physiology?  Have you wondered what metrics you should be looking at when resuscitating a patient that has a beating heart and a ECMO flow?  Dr. Sage Whitmore, an ED Intensivist from Nashville with ECMO training from UMichigan, leads us through the basic to the tough questions of ECMO physiology.

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Have you ever wondered about how initiating ECMO changes the cardiovascular physiology?  Have you wondered what metrics you should be looking at when resuscitating a patient that has a beating heart and a ECMO flow?  Dr. Sage Whitmore,
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the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart 33:46
66: Crash VV ECMO https://edecmo.org/66-crash-vv-ecmo/ Mon, 07 Sep 2020 12:50:55 +0000 https://edecmo.org/?p=5885 Have you ever wondered how you would crash someone onto VV ECMO?  Have you ever wondered where is the best place to put the cannulas?  Have stayed up late at night wondering which patients in your department could benefit from VV rather than VA ECMO?  Then this is the episode for you!!  After a few recent cases of crash VV ECMO in our hospital, we have decided to focus on the subject.  Zack gets critical care physician David Willms to answer from a very practical standpoint the who, what, where of crash VVECMO. Have you ever wondered how you would crash someone onto VV ECMO?  Have you ever wondered where is the best place to put the cannulas?  Have stayed up late at night wondering which patients in your department could benefit from VV rather than VA ECMO?  Then this is the episode for you!!  After a few recent cases of crash VV ECMO in our hospital, we have decided to focus on the subject.  Zack gets critical care physician and ECMO director Dr. David Willms to answer from a very practical standpoint the who, what, where of crash VVECMO.

 

 

 

 

 

 

 

 

Great images from Penn – Femoral Jugular approach

Femoral Femoral Approach

 

 

 

 

 

 

 

Aortic Dissection recent paper and Editorial

https://www.resuscitationjournal.com/article/S0300-9572(20)30309-9/fulltext

https://www.resuscitationjournal.com/article/S0300-9572(20)30435-4/pdf

 

]]>
Have you ever wondered how you would crash someone onto VV ECMO?  Have you ever wondered where is the best place to put the cannulas?  Have stayed up late at night wondering which patients in your department could benefit from VV rather than VA ECMO?
 



 

 

 

 

 

 

 

Great images from Penn - Femoral Jugular approach



Femoral Femoral Approach



 

 

 

 

 

 

 

Aortic Dissection recent paper and Editorial

https://www.resuscitationjournal.com/article/S0300-9572(20)30309-9/fulltext

https://www.resuscitationjournal.com/article/S0300-9572(20)30435-4/pdf

 ]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart 36:06
65: ECPR Journal Club: Dual Sequential Defibrillation, CT after ECMO, and much, much more https://edecmo.org/65-ecpr-journal-club-dual-sequential-defibrillation-ct-after-ecmo-and-much-much-more/ Sat, 23 May 2020 08:43:20 +0000 https://edecmo.org/?p=5725 This month we tackle a number of topics.  Garrett Sterling is back again with Zack Shinar to talk about cutting edge resuscitation, ECMO, and the interplay between the two.  Dual sequential defibrillation, CT after ECMO initiation, should you perform bystander CPR in the era of Covid, some US ECMO data, and an awesome 3D modeling for ECPR training models.  All in one 30 minute podcast! This month we tackle a number of topics.  Garrett Sterling is back again with Zack to talk about cutting edge resuscitation, ECMO, and the interplay between the two.  Dual sequential defibrillation, CT after ECMO initiation, should you perform bystander CPR in the era of Covid, some US ECMO data, and an awesome 3D modeling for ECPR training models.  All in one 30 minute podcast!
Reverse CPR – better systolic BPs
Brown J., Rogers J., Soar J. Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review. Resuscitation. 2001;50:233–238. [PubMed] [Google Scholar]
Mazer S.P., Weisfeldt M., Bai D. Reverse CPR: a pilot study of CPR in the prone position. Resuscitation. 2003;57:279–285. [PubMed] [Google Scholar] DOI:  10.1016/s0300-9572(03)00037-6
Wei J., Tung D., Sue S.H., Wu S., van Chuang Y.C., Chang C.Y. Cardiopulmonary resuscitation in prone position: A simplified method for outpatients. Journal of the Chinese Medical Association. 2006;69:202–206. [PubMed] [Google Scholar]
SLides on Prone CPR
Risk to providers of CPR in Covid
 
Fear of Covid in CPR
Witnesses still providing CPR in Covid era – 53 vs. 49% in Paris
Witnesses didn’t provide in Sydney
Dual Sequential Defibrillation (DSD)
Columbus Ohio Paramedics – http://dx.doi.org/10.1016/j.resuscitation.2016.08.002
San Antonio Texas – no benefit of DSD – http://dx.doi.org/10.1016/j.resuscitation.2016.06.011
Damaged Defibrillator from DSD – DOI: 10.1016/j.annemergmed.2017.04.005
Toronto – Cheskes RCT -DSD and vector change better than standard defibrillation –  https://doi.org/10.1016/j.resuscitation.2020.02.010
National Data on ECMO use in US
J. Hadaya, et al., National trends in utilization and outcomes of extracorporeal support for in- and
out-of-hospital cardiac arrest, Resuscitation (2020), https://doi.org/10.1016/j.resuscitation.2020.02.034
Early CT after ECMO
https://doi.org/10.1016/j.resuscitation.2019.11.024
3d printed  ECPR modeling
https://doi.org/10.1016/j.resuscitation.2020.01.032
]]>
This month we tackle a number of topics.  Garrett Sterling is back again with Zack Shinar to talk about cutting edge resuscitation, ECMO, and the interplay between the two.  Dual sequential defibrillation, CT after ECMO initiation,

Reverse CPR - better systolic BPs

Brown J., Rogers J., Soar J. Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review. Resuscitation. 2001;50:233–238. [PubMed] [Google Scholar]


Mazer S.P., Weisfeldt M., Bai D. Reverse CPR: a pilot study of CPR in the prone position. Resuscitation. 2003;57:279–285. [PubMed] [Google Scholar] DOI:   33:44
64: Contraindicated??? – Long Live the Aortic Dissection with Garrett Sterling https://edecmo.org/64-contraindicated-long-live-the-aortic-dissection-with-garrett-sterling/ Thu, 23 Apr 2020 19:28:15 +0000 https://edecmo.org/?p=5544 In this episode, Zack Shinar introduces a new physician to the podcast - Garrett Sterling.  Garrett and Zack discuss the sticky topic of ECMO for aortic dissection.  This traverses everything from VA ECMO in ECPR to VVECMO for pulmonary edema.  They go through the literature on the subject and make some conclusions based on this data. The ultimate question - "Is Aortic Dissection a Contraindication for ECMO?" Aortic Dissection is a contraindication for ECMO….or is it?  In this episode, Zack Shinar and Garrett Sterling discuss the sticky topic of ECMO for aortic dissection.  They discuss a recent case where Joe Bellezzo, Karl Limmer, Craig Larsen, and the entire Sharp team save a Type A aortic dissection with cardiac arrest.

Zack and Garrett traverse the details around ECMO in aortic dissection ranging from VA ECMO in ECPR to VVECMO for pulmonary edema.  They go through the literature on the subject and make some conclusions based on this data. The ultimate question – “Is Aortic Dissection a Contraindication for ECMO?”

Joe’s interview of Michael – Great to hear his memory of the event.

Michael’s podcast on his experience – The Heart of the Matter

 

 

Hou XT, Sun YQ, Zhang HJ, Zheng SH, Liu YY, Wang JG. Femoral artery

cannulation in Stanford type A aortic dissection operations. Asian Cardiovasc

Thorac Ann. 2006 Feb;14(1):35-7. PubMed PMID: 16432116.

 

Kelly C, Ockerse P, Glotzbach JP, Jedick R, Carlberg M, Skaggs J, Morgan DE.

Transesophageal echocardiography identification of aortic dissection during

cardiac arrest and cessation of ECMO initiation. Am J Emerg Med. 2019

Jun;37(6):1214.e5-1214.e6. doi: 10.1016/j.ajem.2019.02.039. Epub 2019 Feb 27.

PubMed PMID: 30862393.

 

Yukawa T, Sugiyama K, Miyazaki K, Tanabe T, Ishikawa S, Hamabe Y. Treatment of

a patient with acute aortic dissection using extracorporeal cardiopulmonary

resuscitation after an out-of-hospital cardiac arrest: a case report. Acute Med

Surg. 2017 Dec 19;5(2):189-193. doi: 10.1002/ams2.324. eCollection 2018 Apr.

PubMed PMID: 29657734; PubMed Central PMCID: PMC5891112

]]> In this episode, Zack Shinar introduces a new physician to the podcast - Garrett Sterling.  Garrett and Zack discuss the sticky topic of ECMO for aortic dissection.  This traverses everything from VA ECMO in ECPR to VVECMO for pulmonary edema.
Zack and Garrett traverse the details around ECMO in aortic dissection ranging from VA ECMO in ECPR to VVECMO for pulmonary edema.  They go through the literature on the subject and make some conclusions based on this data. The ultimate question - "Is Aortic Dissection a Contraindication for ECMO?"



Joe's interview of Michael - Great to hear his memory of the event.

Michael's podcast on his experience - The Heart of the Matter

 

 

Hou XT, Sun YQ, Zhang HJ, Zheng SH, Liu YY, Wang JG. Femoral artery

cannulation in Stanford type A aortic dissection operations. Asian Cardiovasc

Thorac Ann. 2006 Feb;14(1):35-7. PubMed PMID: 16432116.

 

Kelly C, Ockerse P, Glotzbach JP, Jedick R, Carlberg M, Skaggs J, Morgan DE.

Transesophageal echocardiography identification of aortic dissection during

cardiac arrest and cessation of ECMO initiation. Am J Emerg Med. 2019

Jun;37(6):1214.e5-1214.e6. doi: 10.1016/j.ajem.2019.02.039. Epub 2019 Feb 27.

PubMed PMID: 30862393.

 

Yukawa T, Sugiyama K, Miyazaki K, Tanabe T, Ishikawa S, Hamabe Y. Treatment of

a patient with acute aortic dissection using extracorporeal cardiopulmonary

resuscitation after an out-of-hospital cardiac arrest: a case report. Acute Med

Surg. 2017 Dec 19;5(2):189-193. doi: 10.1002/ams2.324. eCollection 2018 Apr.

PubMed PMID: 29657734; PubMed Central PMCID: PMC5891112]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart 32:28 63: Covid and ECMO – Who do we cannulate? with Jenelle Badulak https://edecmo.org/63-covid-and-ecmo-who-do-we-cannulate-with-jenelle-badulak/ Sun, 22 Mar 2020 05:31:02 +0000 https://edecmo.org/?p=5619 "Normal life is changing.  It is now a covid 19 life" - Bin Cao I write this with some trepidation as well as pride in the role we get to play as we begin the surge of Covid 19 in the United States.  Today we will address the use of ECMO in Covid with an expert in ECMO who is in the throws of the worst outbreak of the United States - Seattle, Washington.  Jenelle Badulak and I give you a short yet powerful discussion about who we should put on ECMO with Covid. Hosts - Zack Shinar, Jenelle Badulak “Normal life is changing.  It is now a covid 19 life” – Bin Cao

I write this with some trepidation as well as pride in the role we all get to play in Covid 19.  The sure in the US and many other places worldwide is just beginning.  It is on us to seek guidance from those who have gone through this already.  Today we will address the use of ECMO in Covid with an expert in ECMO who is in the throws of the worst outbreak of the United States – Seattle, Washington.  Jenelle Badulak and I give you a short yet powerful discussion about what Covid patients should receive ECMO.

Take homes for decision to initiate- comorbidities (HTN, DM especially), single organ dysfunction, young age, trajectory of course

Hosts – Jenelle Badulak, Zack Shinar

 

ECMO guidance for Coronavirus

  • MERS ECMO Data
    • Alshahrani MS, Sindi A, Alshamsi F, Al-Omari A, El Tahan M, Alahmadi B, Zein A, Khatani N, Al-Hameed F, Alamri S, Abdelzaher M, Alghamdi A, Alfousan F, Tash A, Tashkandi W, Alraddadi R, Lewis K, Badawee M, Arabi YM, Fan E, Alhazzani W. Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus. Ann Intensive Care. 2018 Jan 10;8(1):3. doi: 10.1186/s13613-017-0350-x. PubMed PMID: 29330690; PubMed Central PMCID: PMC5768582
  • Chinese Society of Extracorporeal Life Support. [Recommendations on extracorporeal life support for critically ill patients with novel coronavirus pneumonia]. Zhonghua Jie He He Hu Xi Za Zhi. 2020 Feb 9;43(0):E009. doi: 10.3760/cma.j.issn.1001-0939.2020.0009. [Epub ahead of print] Chinese. PubMed PMID: 32035430.
    • http://rs.yiigle.com/yufabiao/1180132.htm
    • Inclusion criteria under this paper are–>
    • Under optimal ventilation conditions (FiO 2 ≥ 0.8, tidal volume 6 ml / kg, PEEP ≥ 10 cmH 2 O), ECMO can be started if there are no contraindications and one of the following conditions is met 7 , 8 , 14 , 16 , 17 , 18 ] : (1) PaO 2 / FiO 2 <50 mmHg for more than 3 h; (2) PaO 2 / FiO 2 <80 mmHg for more than 6 h; (3) FiO 2 = 1.0, PaO 2 / FiO 2 <100 mmHg; (4) Arterial blood pH <7.25 and PaCO 2 > 60 mmHg for more than 6 hours, and respiratory rate> 35 times / min; (5) When respiratory rate> 35 times / min, blood pH <7.2 The plateau pressure was> 30 cmH 2 O; (6) severe air leak syndrome; (7) combined with cardiogenic shock or cardiac arrest.

 

 

 

]]>
"Normal life is changing.  It is now a covid 19 life" - Bin Cao - I write this with some trepidation as well as pride in the role we get to play as we begin the surge of Covid 19 in the United States.  Today we will address the use of ECMO in Covid wi...


I write this with some trepidation as well as pride in the role we all get to play in Covid 19.  The sure in the US and many other places worldwide is just beginning.  It is on us to seek guidance from those who have gone through this already.  Today we will address the use of ECMO in Covid with an expert in ECMO who is in the throws of the worst outbreak of the United States - Seattle, Washington.  Jenelle Badulak and I give you a short yet powerful discussion about what Covid patients should receive ECMO.

Take homes for decision to initiate- comorbidities (HTN, DM especially), single organ dysfunction, young age, trajectory of course

Hosts - Jenelle Badulak, Zack Shinar

 

ECMO guidance for Coronavirus

* MERS ECMO Data

* Alshahrani MS, Sindi A, Alshamsi F, Al-Omari A, El Tahan M, Alahmadi B, Zein A, Khatani N, Al-Hameed F, Alamri S, Abdelzaher M, Alghamdi A, Alfousan F, Tash A, Tashkandi W, Alraddadi R, Lewis K, Badawee M, Arabi YM, Fan E, Alhazzani W. Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus. Ann Intensive Care. 2018 Jan 10;8(1):3. doi: 10.1186/s13613-017-0350-x. PubMed PMID: 29330690; PubMed Central PMCID: PMC5768582
*


* Chinese Society of Extracorporeal Life Support. [Recommendations on extracorporeal life support for critically ill patients with novel coronavirus pneumonia]. Zhonghua Jie He He Hu Xi Za Zhi. 2020 Feb 9;43(0):E009. doi: 10.3760/cma.j.issn.1001-0939.2020.0009. [Epub ahead of print] Chinese. PubMed PMID: 32035430.

* http://rs.yiigle.com/yufabiao/1180132.htm
* Inclusion criteria under this paper are-->
* Under optimal ventilation conditions (FiO 2 ≥ 0.8, tidal volume 6 ml / kg, PEEP ≥ 10 cmH 2 O), ECMO can be started if there are no contraindications and one of the following conditions is met [ 7 , 8 , 14 , 16 , 17 , 18 ] : (1) PaO 2 / FiO 2 <50 mmHg for more than 3 h; (2) PaO 2 / FiO 2 <80 mmHg for more than 6 h; (3) FiO 2 = 1.0, PaO 2 / FiO 2 <100 mmHg; (4) Arterial blood pH <7.25 and PaCO 2 > 60 mmHg for more than 6 hours, and respiratory rate> 35 times / min; (5) When respiratory rate> 35 times / min, blood pH <7.2 The plateau pressure was> 30 cmH 2 O; (6) severe air leak syndrome; (7) combined with cardiogenic shock or cardiac arrest.



 

* Good overall webinar - ECMO considerations start - http://iv.docbook.com.cn/record/app-name/46020/2020-03-19-20-45-14_2020-03-19-21-40-14.mp4

* Slides here - Ning Zhou-The application of ECMO in severe Covid-19 patients


* ELSO Guidance Document

 

 ]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart 23:09
62: Jason Bartos Take 2: The Future of ECPR Now https://edecmo.org/62-jason-bartos-take-2-the-future-of-ecpr-now/ Tue, 18 Feb 2020 14:12:04 +0000 https://edecmo.org/?p=5435 Last month you heard Jason talk about the ECPR program at the University of Minnesota.  This month Zack and Jason talk about post initiation care and the crazy ECPR realities that Demetri, Jason and U of M have created.  The sky is the limit for their team!

Last month you heard Jason talk about the ECPR program at the University of Minnesota.  This month Zack and Jason talk about post initiation care and the crazy ECPR realities that Demetris, Jason and U of M have created.  The sky is the limit for their team!

]]>
Last month you heard Jason talk about the ECPR program at the University of Minnesota.  This month Zack and Jason talk about post initiation care and the crazy ECPR realities that Demetri, Jason and U of M have created.
Last month you heard Jason talk about the ECPR program at the University of Minnesota.  This month Zack and Jason talk about post initiation care and the crazy ECPR realities that Demetris, Jason and U of M have created.  The sky is the limit for their team!]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart 27:26
61: Jason Bartos – ECPR Redefined https://edecmo.org/61-jason-bartos-ecpr-redefined/ Thu, 30 Jan 2020 14:18:48 +0000 https://edecmo.org/?p=5385 Jason Bartos and his crew at the University of Minnesota have revolutionized the concept of ECPR for out of hospital cardiac arrests.  His crew are interventional cardiologists who take OHCA straight to the cardiac cath lab.  They have initiate times of around 6-8 minutes and have neurologically intact survival rates higher than 30%.  Below are two of Jason’s recent papers which every person who considers themselves an ECPR fan should pour over with a fine-toothed comb.  There is so much in these papers.  We split this interview into two pieces because there is so many pearls in it.

Jason Bartos and his crew at the University

Image result for university of minnesota cardiology"

of Minnesota have revolutionized the concept of ECPR for out of hospital cardiac arrests.  His crew are interventional cardiologists who take OHCA straight to the cardiac cath lab.  They have initiate times of around 6-8 minutes and have neurologically intact survival rates higher than 30%.  Below are two of Jason’s recent papers which every person who considers themselves an ECPR fan should pour over with a fine-toothed comb.  There is so much in these papers.  We split this interview into two pieces because there is so many pearls in it.

 

Outcomes

Resuscitation paper – 48% survival in 100 patients

Circulation paper 2020– 33% vs. 23% ALPS

  • Cohort who had VF/VT and one shock vs. a cohort who had VF/VT and failed to ROSC at the scene, in the ambulance, and then all the way to the hospital.
  • OHCA – > Straight to the Cath lab –> Get on ECMO –> Go to CCU under Cards care.
  • Inclusion criteria – Vf/vt, lactate <18, paO2 >50,ETCO2>10

 

References:

Bartos JA, Grunau B, Carlson C, Duval S, Ripeckyj A, Kalra R, Raveendran G,
John R, Conterato M, Frascone RJ, Trembley A, Aufderheide TP, Yannopoulos D.
Improved Survival with Extracorporeal Cardiopulmonary Resuscitation Despite
Progressive Metabolic Derangement Associated with Prolonged Resuscitation.
Circulation. 2020 Jan 3. doi: 10.1161/CIRCULATIONAHA.119.042173. [Epub ahead of
print] PubMed PMID: 31896278.

Bartos JA, Carlson K, Carlson C, Raveendran G, John R, Aufderheide TP,
Yannopoulos D. Surviving refractory out-of-hospital ventricular fibrillation
cardiac arrest: Critical care and extracorporeal membrane oxygenation management.
Resuscitation. 2018 Nov;132:47-55. doi: 10.1016/j.resuscitation.2018.08.030. Epub
2018 Aug 29. PubMed PMID: 30171974.
]]>
Jason Bartos and his crew at the University - of Minnesota have revolutionized the concept of ECPR for out of hospital cardiac arrests.  His crew are interventional cardiologists who take OHCA straight to the cardiac cath lab.
Jason Bartos and his crew at the University



of Minnesota have revolutionized the concept of ECPR for out of hospital cardiac arrests.  His crew are interventional cardiologists who take OHCA straight to the cardiac cath lab.  They have initiate times of around 6-8 minutes and have neurologically intact survival rates higher than 30%.  Below are two of Jason’s recent papers which every person who considers themselves an ECPR fan should pour over with a fine-toothed comb.  There is so much in these papers.  We split this interview into two pieces because there is so many pearls in it.

 

Outcomes

Resuscitation paper - 48% survival in 100 patients

Circulation paper 2020– 33% vs. 23% ALPS

* Cohort who had VF/VT and one shock vs. a cohort who had VF/VT and failed to ROSC at the scene, in the ambulance, and then all the way to the hospital.
* OHCA - > Straight to the Cath lab --> Get on ECMO --> Go to CCU under Cards care.
* Inclusion criteria - Vf/vt, lactate <18, paO2 >50,ETCO2>10

 

References:
Bartos JA, Grunau B, Carlson C, Duval S, Ripeckyj A, Kalra R, Raveendran G,
John R, Conterato M, Frascone RJ, Trembley A, Aufderheide TP, Yannopoulos D.
Improved Survival with Extracorporeal Cardiopulmonary Resuscitation Despite
Progressive Metabolic Derangement Associated with Prolonged Resuscitation.
Circulation. 2020 Jan 3. doi: 10.1161/CIRCULATIONAHA.119.042173. [Epub ahead of
print] PubMed PMID: 31896278.


Bartos JA, Carlson K, Carlson C, Raveendran G, John R, Aufderheide TP,
Yannopoulos D. Surviving refractory out-of-hospital ventricular fibrillation
cardiac arrest: Critical care and extracorporeal membrane oxygenation management.
Resuscitation. 2018 Nov;132:47-55. doi: 10.1016/j.resuscitation.2018.08.030. Epub
2018 Aug 29. PubMed PMID: 30171974.]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart 36:22
60: ECPR 2.0 with Scott Weingart https://edecmo.org/60-ecpr-2-0-with-scott-weingart/ Tue, 03 Dec 2019 01:12:28 +0000 https://edecmo.org/?p=5252 Today's episode focuses on the differences between ECMO physiology in the patient in cardiogenic shock versus the one in cardiac arrest.      We’ve had some recent episodes on ECMO physiology.  Today’s episode focuses on the differences between ECMO physiology in the patient in cardiogenic shock versus the one in cardiac arrest. Scott Weingart talks with Zack about how the difference between these two patient populations is HUGE!  Scott also mentions details about cannulation and some critical post ECMO initiation pearls.

 

 

 

 

ECPR 2.0

The Patient
1. OOH Cardiac Arrest Patients are Different

Cannulation
2. Ultrasound-Guided Percutaneous Placement
3. Wire choices
4. Wire Location Verification
5. Small arterial cannulae
6. Simpler Circuits

Post-Pump Critical Care
7. Find the Injuries
8. Mandatory leg perfusion
9. Lower Anticoagulation Goals
10. Lower Flow Goals
11. Try to avoid venting – Truby et al. PMID:28422817, less is more
12. Understanding Cardiac Prognostication / Stunning
13. Understanding Neuro Prognostication
14. Protection/Ownership
15. In it for the Long Haul

 

]]>
Today's episode focuses on the differences between ECMO physiology in the patient in cardiogenic shock versus the one in cardiac arrest.
 

 

 

 
ECPR 2.0
The Patient
1. OOH Cardiac Arrest Patients are Different

Cannulation
2. Ultrasound-Guided Percutaneous Placement
3. Wire choices
4. Wire Location Verification
5. Small arterial cannulae
6. Simpler Circuits

Post-Pump Critical Care
7. Find the Injuries
8. Mandatory leg perfusion
9. Lower Anticoagulation Goals
10. Lower Flow Goals
11. Try to avoid venting - Truby et al. PMID:28422817, less is more
12. Understanding Cardiac Prognostication / Stunning
13. Understanding Neuro Prognostication
14. Protection/Ownership
15. In it for the Long Haul

 ]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart 51:07
59: Partial REBOA and US PreHospital ECPR Revisited https://edecmo.org/59-partial-reboa-and-us-prehospital-ecpr-revisited/ Mon, 04 Nov 2019 19:18:49 +0000 https://edecmo.org/?p=5225 This month we discuss two different topics we've recently had on the podcast.  Albuquerque had started the first US prehospital ECPR program.... and now they have the first patient as well.  Jon and Darren will share with us the exciting news.  Second, we recently had Matt Martin on the podcast talking about partial REBOA.  We got tons of email about this.  This month Zaf Qasim and Austin Johnson come on to talk about some of the controversial aspects of partial REBOA.  Zaf also gives us a great update on the state of REBOA in the world. This month we discuss two different topics we’ve recently had on the podcast.  Albuquerque had started the first US prehospital ECPR program…. and now they have the first patient as well.  Jon and Darren will share with us the exciting news.  Second, we recently had Matt Martin on the podcast talking about partial REBOA.  We got tons of email about this.  This month Zaf Qasim and Austin Johnson come on to talk about some of the controversial aspects of partial REBOA.  Zaf also gives us a great update on the state of REBOA in the world.

 

]]>
This month we discuss two different topics we've recently had on the podcast.  Albuquerque had started the first US prehospital ECPR program.... and now they have the first patient as well.  Jon and Darren will share with us the exciting news.


 ]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 35:44
58: First U.S. Pre-Hospital ECPR Program https://edecmo.org/58-first-american-pre-hospital-ecpr-program/ Mon, 30 Sep 2019 19:56:29 +0000 https://edecmo.org/?p=5114 The U.S. has seen pre-hospital programs spring up in Paris, UK, and Australia.  It was thought that due to billing issues this could never happen in America....but it has.  Jon Marinaro and Darren Braude have accomplished this against all odds.  Zack interviews the two of them on how they were able to accomplish this task amidst the many financial, logistic, and medical problems surrounding this monumental task. The U.S. has seen pre-hospital programs spring up in Paris, UK, and Australia.  It was thought that due to billing issues this could never happen in America….but it has.  Jon Marinaro and Darren Braude have accomplished this against all odds.  Zack interviews the two of them on how they were able to accomplish this task amidst the many financial, logistic, and medical problems surrounding this monumental task.

 

 

 

 

The Albuquerque Bean Dip!!  Love this organization from cleanse to cannulation

 

Update:

News story

]]>
The U.S. has seen pre-hospital programs spring up in Paris, UK, and Australia.  It was thought that due to billing issues this could never happen in America....but it has.  Jon Marinaro and Darren Braude have accomplished this against all odds.
 

 

 

 

The Albuquerque Bean Dip!!  Love this organization from cleanse to cannulation



 
Update:
News story]]>
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57: The New REBOA catheter – Perfecting the Partial Occlusion https://edecmo.org/57-the-new-reboa-catheter-perfecting-the-partial-occlusion/ Sat, 07 Sep 2019 19:13:39 +0000 https://edecmo.org/?p=4783 Over the last two years, partial or intermittent REBOA has been thought to be a significant advantage over complete REBOA.  How to do this and how to use our current imperfect catheters in this arena is still in question.  Matthew Martin and his colleagues at Madigan Medical Center have published the first study using the Prytime's new catheter for partial REBOA.  Zack interviews Matt in this episode about his latest paper in Journal of Trauma and Acute Surgery.  Dr. Martin is extensively published in the field and offers his insight in the specific flows that maximize survival within the conflicting problems of hemorrhagic shock and lower body ischemia. Over the last two years, partial or intermittent REBOA has been thought to be a significant advantage over complete REBOA.  How to do this and how to use our current imperfect catheters in this arena is still in question.
 

 

 

 
Efficacy of intermittent versus standard resuscitative endovascular balloon occlusion of the aorta in a lethal solid organ injury model.


Kuckelman J, Derickson M, Barron M, Phillips CJ, Moe D, Levine T, Kononchik JP, Marko ST, Eckert M, Martin MJ.
J Trauma Acute Care Surg. 2019 Jul;87(1):9-17. doi: 10.1097/TA.0000000000002307.





PMID: 31259868

TITRATE TO EQUILIBRATE AND NOT EXSANGUINATE!: CHARACTERIZATION AND VALIDATION OF A NOVEL PARTIAL RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA CATHETER IN NORMAL AND HEMORRHAGIC SHOCK CONDITIONS.


Forte D, Do WS, Weiss JB, Sheldon RR, Kuckelman JP, Eckert MJ, Martin MJ.
J Trauma Acute Care Surg. 2019 May 21. doi: 10.1097/TA.0000000000002378. [Epub ahead of print]





PMID: 31135770

Resuscitative endovascular balloon occlusion of the aorta induced myocardial injury is mitigated by endovascular variable aortic control.


Beyer CA, Hoareau GL, Tibbits EM, Davidson AJ, DeSoucy ED, Simon MA, Grayson JK, Neff LP, Williams TK, Johnson MA.
J Trauma Acute Care Surg. 2019 Sep;87(3):590-598. doi: 10.1097/TA.0000000000002363.





PMID: 311453810

Selective Aortic Arch Perfusion with fresh whole blood or HBOC-201 reverses hemorrhage-induced traumatic cardiac arrest in a lethal model of non-compressible torso hemorrhage.


Hoops HE, Manning JE, Graham TL, McCully BH, McCurdy SL, Ross JD.
J Trauma Acute Care Surg. 2019 Apr 18. doi: 10.1097/TA.0000000000002315. [Epub ahead of print]





PMID:  31211744








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56: Pressors, Fluid, or Flow – Optimizing ECMO Physiology https://edecmo.org/56-pressors-fluid-or-flow-optimizing-ecmo-physiology/ Mon, 08 Jul 2019 06:05:55 +0000 https://edecmo.org/?p=4717 A post arrest patient just got initiated on ECMO.  Do you give fluids, add pressors, or increase flow?  Marc Dickstein, an anesthesiologist from Columbia University and an expert in the physiology of ECMO, talks with Zack about how to manage these patients, what diagnostics we need and how to optimize your use of the machine.  This talk is a must for everyone starting ECPR in their departments. A post arrest patient just got initiated on ECMO.  Do you give fluids, add pressors, or increase flow?  Marc Dickstein, an anesthesiologist from Columbia University and an expert in the physiology of ECMO, talks with Zack about how to manage these pati...


Marc's ECMO physiology website Harvi

Marc's ASAIO article on ECMO physiology -

Dickstein ML. The Starling Relationship and Veno-Arterial ECMO: Ventricular Distension Explained. ASAIO J. 2018 Jul/Aug;64(4):497-501. doi: 10.1097/MAT.0000000000000660. PubMed PMID: 29076945.

Zack's recent Resus Editorial on Impella
Shinar Z. Is the "Unprotected Heart" a clinical myth? Use of IABP, Impella,
and ECMO in the acute cardiac patient. Resuscitation. 2019 May 21. pii:
S0300-9572(19)30173-X. doi: 10.1016/j.resuscitation.2019.05.005. [Epub ahead of
print] PubMed PMID: 31125528]]>
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55 – Anticoagulation of the ECMO Patient with Troy Seelhammer https://edecmo.org/55-anticoagulation-of-the-ecmo-patient-with-troy-seelhammer/ Tue, 04 Jun 2019 17:34:00 +0000 https://edecmo.org/?p=4661 Do you give heparin to your ECMO patients?  Well, let's rethink this.  This episode is All Things Anticoagulation!  Zack talks with Troy Seelhammer, an intensivist from Mayo Clinic Rochester.  He manages ECMO patients in his daily practice there.  He has become a master of the subject of anticoagulation.  He will talk about heparin, bilvalirudin, or maybe no anticoagulation.  He talks about the when to be aggressive and when to cut back.  Below is a wonderful synopsis of Troy's thoughts on anticoagulation on pump. Do you give heparin to your ECMO patients?  Well, let's rethink this.  This episode is All Things Anticoagulation!  Zack talks with Troy Seelhammer, an intensivist from Mayo Clinic Rochester.  He manages ECMO patients in his daily practice there.
Do you give heparin to your ECMO patients?  Well, let's rethink this.  This episode is All Things Anticoagulation!  Zack talks with Troy Seelhammer, an intensivist from Mayo Clinic Rochester.  He manages ECMO patients in his daily practice there.  He has become a master of the subject of anticoagulation.  He will talk about heparin, bilvalirudin, or maybe no anticoagulation.  We talk about how TEG can affect our management.  We talk about PCC and Protamine when bleeding just won't stop.  He talks about the when to be aggressive and when to cut back.  Below is a wonderful synopsis of Troy's thoughts on anticoagulation on pump.

 

Goal Heparin levels are far from perfect but some suggestions

APTT 1.5 to 2.5 times normal

ACT level - 180-220 seconds

Antithrombin Levels - next generation

 

Seelhammer doc on Bivalirudin - Bivalirudin & TEG During ECMO

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54: Confirmation of Wire Placement with Sacha Richardson https://edecmo.org/54-confirmation-of-wire-placement-with-sacha-richardson/ Wed, 08 May 2019 16:07:07 +0000 https://edecmo.org/?p=4572 In this episode, Sacha Richardson talks with Zack about a problem common to all ECPR programs- how do we confirm the placement of the wires?  During chest compressions and even in patients with a pulse, confirmation of which vessel you have cannulated can be difficult.  Sacha shares some tricks and trips on how to get real time confirmation of the wires.  Sacha also gives us a preview of some of the exciting endeavors that he has undertaken in Melbourne with pre-hospital ECMO. In this episode, Sacha Richardson talks with Zack about a problem common to all ECPR programs- how do we confirm the placement of the wires?  During chest compressions and even in patients with a pulse, confirmation of which vessel you have cannulated ... the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 23:18 53b: Resuscitationist Inserted Distal Perfusion Catheter with Chris Couch https://edecmo.org/53b-resuscitationist-inserted-distal-perfusion-catheter-with-chris-couch/ Thu, 04 Apr 2019 16:31:40 +0000 https://edecmo.org/?p=4608 In this episode, we again explore the world of the distal perfusion catheter.  You heard from Joe Dubose the vascular surgeons point of view; now let's see how non-surgeon resuscitationists are dealing with this problem.  You will hear from Chris Couch, a critical care trained emergency physician from Dallas Texas and his colleague Omar Hernandez who have some novel thoughts and experiences related to when and how we insert these catheters.  You will hear about checking compartment pressures, poor man's way to "fluoro" your catheter, and much more. In this episode, we again explore the world of the distal perfusion catheter.  You heard from Joe Dubose the vascular surgeons point of view; now let's see how non-surgeon resuscitationists are dealing with this problem.
 

In this episode, we again explore the world of the distal perfusion catheter.  You heard from Joe Dubose the vascular surgeons point of view; now let's see how non-surgeon resuscitationists are dealing with this problem.  You will hear from Chris Couch, a critical care trained emergency physician from Dallas Texas and his colleague Omar Hernandez who have some novel thoughts and experiences related to when and how we insert these catheters.  You will hear about checking compartment pressures, poor man's way to "fluoro" your catheter, and much more.

 

Great summary of supporting literature - DPC Lit Search

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53: Distal Perfusion Catheter with Joe Dubose https://edecmo.org/53-distal-perfusion-catheter-with-joe-dubose/ Mon, 01 Apr 2019 17:40:10 +0000 https://edecmo.org/?p=4561 Episode 53 is all about the distal perfusion catheter12.  We are inserting a 15-19 Fr catheter into the femoral artery.  This limits the flow of blood to the affected extremity.  Many institutions have gone to mandatory distal perfusion catheters.  This episode is all about those catheters - when, how, which, and where.  Joe Dubose, the world reknown vascular and trauma surgeon, joins us to discuss the details of this important piece of post pump initiation. Episode 53 is all about the distal perfusion catheter12.  We are inserting a 15-19 Fr catheter into the femoral artery.  This limits the flow of blood to the affected extremity.  Many institutions have gone to mandatory distal perfusion catheters.


Take Homes -

* Common Femoral -> Superficial Femoral Artery or Posterior Tibial/Dorsalis Pedis
* Check distal perfusion frequently
* 5-7 Fr Catheters
* Doppler/Temperature/Color of distal extremity
* Remember side port of arterial ECMO catheter significantly limits the flow dynamics through the catheter

References



1.
Kaufeld T, Beckmann E, Ius F, et al. Risk factors for critical limb ischemia in patients undergoing femoral cannulation for venoarterial extracorporeal membrane oxygenation: Is distal limb perfusion a mandatory approach? Perfusion. February 2019:267659119827231. [PubMed]




2.
Lamb K, DiMuzio P, Johnson A, et al. Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation. J Vasc Surg. 2017;65(4):1074-1079. [PubMed]



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the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 27:28
52: Brain Freeze- Selective Retrograde Cerebral Perfusion for Intra-Arrest Neuroprotection https://edecmo.org/52-brain-freeze-selective-retrograde-cerebral-perfusion-for-intra-arrest-neuroprotection/ Tue, 05 Mar 2019 18:56:24 +0000 https://edecmo.org/?p=4547 We've all heard of therapeutic hypothermia.  Some of us have heard of deep hypothermia for traumatic arrest.  But what about deep regional hypothermia of brain for cardiac arrest!  Zack interviewed Rob Schultz, a CT surgeon resident from Calgary who is doing research on deep hypothermia of the brain using some of the tactics that are utilized in operating room.  His stuff is mind blowing! We've all heard of therapeutic hypothermia.  Some of us have heard of deep hypothermia for traumatic arrest.  But what about deep regional hypothermia of brain for cardiac arrest!  Zack interviewed Rob Schultz,
We've all heard of therapeutic hypothermia.  Some of us have heard of deep hypothermia for traumatic arrest.  But what about deep regional hypothermia of brain for cardiac arrest!  Zack interviewed Rob Schultz, a CT surgeon resident from Calgary who is doing research on deep hypothermia of the brain using some of the tactics that are utilized in operating room.  His stuff is mind blowing!
References



1.
Milewski RK, Pacini D, Moser GW, et al. Retrograde and Antegrade Cerebral Perfusion: Results in Short Elective Arch Reconstructive Times. The Annals of Thoracic Surgery. 2010;89(5):1448-1457. doi:10.1016/j.athoracsur.2010.01.056




2.
Keeling WB, Leshnower BG, Hunting JC, Binongo J, Chen EP. Hypothermia and Selective Antegrade Cerebral Perfusion Is Safe for Arch Repair in Type A Dissection. The Annals of Thoracic Surgery. 2017;104(3):767-772. doi:10.1016/j.athoracsur.2017.02.066




3.
Papadopoulos N, Risteski P, Hack T, et al. Is More than One Hour of Selective Antegrade Cerebral Perfusion in Moderate-to-Mild Systemic Hypothermic Circulatory Arrest for Surgery of Acute Type A Aortic Dissection Safe? Thorac cardiovasc Surg. 2017;66(03):215-221. doi:10.1055/s-0037-1604451




4.
Perreas K, Samanidis G, Thanopoulos A, et al. Antegrade or Retrograde Cerebral Perfusion in Ascending Aorta and Hemiarch Surgery? A Propensity-Matched Analysis. The Annals of Thoracic Surgery. 2016;101(1):146-152. doi:10.1016/j.athoracsur.2015.06.029




5.
McCullough J, Zhang N, Reich D, et al. Cerebral metabolic suppression during hypothermic circulatory arrest in humans. Ann Thorac Surg. 1999;67(6):1895-1899; discussion 1919-21. [PubMed]




6.
Yan T, Bannon P, Bavaria J, et al. Consensus on hypothermia in aortic arch surgery. Ann Cardiothorac Surg. 2013;2(2):163-168. [PubMed]



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51 – Proximal Balloon Occlusion for Cardiac Arrest https://edecmo.org/51-proximal-balloon-occlusion-for-cardiac-arrest/ Tue, 12 Feb 2019 18:34:55 +0000 https://edecmo.org/?p=4505  You've heard of ECMO for cardiac arrest- utilizing a mechanical pump to aid in perfusion of the coronaries.  What if you can't do ECMO?  What if your resources are such that simply can't lug a 10 kilogram machine out into the field?  Well, Jostein Brede may have something for you to consider.  He and several other places worldwide are on the forefront of using a REBOA catheter to occlude the proximal aorta during chest compressions in hopes that coronary perfusion pressure increases.  This would subsequently improve chance of return of spontaneous circulation and overall survivorship.  Maybe this is the band-aid that can be used in austere environments like rural Norway where the temperatures are extreme, the people are sparse, but the physicians are motivated.  You've heard of ECMO for cardiac arrest- utilizing a mechanical pump to aid in perfusion of the coronaries.  What if you can't do ECMO?  What if your resources are such that simply can't lug a 10 kilogram machine out into the field?  Well, References



1.
Daley J, Morrison JJ, Sather J, Hile L. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to ACLS in non-traumatic cardiac arrest. T. 2017;35(5):731-736. doi:10.1016/j.ajem.2017.01.010




2.
Aslanger E, Golcuk E, Oflaz H, et al. Intraaortic balloon occlusion during refractory cardiac arrest. A case report. R. 2009;80(2):281-283. doi:10.1016/j.resuscitation.2008.10.017



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50b Inter-Facility Transport of ECMO patients Part 2 of 2 https://edecmo.org/50b-inter-facility-transport-of-ecmo-patients-part-2-of-2/ Wed, 05 Dec 2018 22:20:14 +0000 https://edecmo.org/?p=4377 This is part 2 of Transport of ECMO patients.  Mikael Broman is one of the world's leaders on ECMO transport.  He works at the Karolinska institute in Sweden and has and continues to publish in the arena of ECMO transport.  As you will see, he offers a world of experience and certainly some critical information that we would all benefit from listening to.  I'm a smarter ECMO-tologist as a result of Micke! This is part 2 of Transport of ECMO patients.  Mikael Broman is one of the world's leaders on ECMO transport.  He works at the Karolinska institute in Sweden and has and continues to publish in the arena of ECMO transport.  As you will see,


s and continues to publish in the arena of ECMO transport.  As you will see, he offers a world of experience and certainly some critical information that we would all benefit from listening to.  I'm a smarter ECMO-tologist as a result of Micke!1234

 

 

 

 

ELSO transport guidelines -https://www. elso.org/Portals/0/Files/ELSO%20GUIDELINES%20 FOR%20ECMO%20TRANSPORT_May2015.pdf

 
References



1.
Bryner B, Cooley E, Copenhaver W, et al. Two Decades’ Experience With Interfacility Transport on Extracorporeal Membrane Oxygenation. T. 2014;98(4):1363-1370. doi:10.1016/j.athoracsur.2014.06.025




2.
Javidfar J, Brodie D, Takayama H, et al. Safe Transport of Critically Ill Adult Patients on Extracorporeal Membrane Oxygenation Support to a Regional Extracorporeal Membrane Oxygenation Center. A. 2011;57(5):421-425. doi:10.1097/mat.0b013e3182238b55




3.
Broman LM. Inter-hospital transports on extracorporeal membrane oxygenation in different health-care systems. J. 2017;9(9):3425-3429. doi:10.21037/jtd.2017.07.93




4.
Ericsson A, Frenckner B, Broman L. Adverse Events during Inter-Hospital Transports on Extracorporeal Membrane Oxygenation. Prehosp Emerg Care. 2017;21(4):448-455. [PubMed]



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50a Inter-facility Transport of ECMO patients Part 1 of 2 https://edecmo.org/50a-inter-facility-transport-of-ecmo-patients-part-1-of-2/ Wed, 05 Dec 2018 20:29:30 +0000 https://edecmo.org/?p=4327 This month we are looking at how to transport patients from one facility to another on ECMO.  This is difficult task full of potential catastrophes.  Zack interviews Leon Eydelman, an ER/Critical Care physician from Chicago, and Michael Broman out of Karolinska in Sweden.  Leon will be bringing us up to speed on what to do, potential fails, and how to start the process of setting up a transport process for ECMO patients.  Dr. Eydelman will be teaching a new section at Reanimate this January specifically geared toward the transport of patients.  So if you are a nurse, medic, perfusionist, RT, or physician involved in the transport of ECMO patients you will not want to miss Leon's section  Sign up at Reanimateconference.com.  Part 2 of this podcast includes the interview with Dr. Broman which will blow your mind.  So much great stuff in both of these interviews. This month we are looking at how to transport patients from one facility to another on ECMO.  This is difficult task full of potential catastrophes.  Zack interviews Leon Eydelman, an ER/Critical Care physician from Chicago,
This month we are looking at how to transport patients from one facility to another on ECMO.  This is a difficult task, full of potential catastrophes.  Zack interviews Leon Eydelman, an ER/Critical Care physician from Chicago, and Michael Broman out of Karolinska in Sweden.  Leon will be bringing us up to speed on what to do, potential fails, and how to start the process of setting up a transport process for ECMO patients.  Dr. Eydelman will be teaching a new section at Reanimate this January specifically geared toward the transport of patients.  So if you are a nurse, medic, perfusionist, or RT involved in the transport of ECMO patients you will not want to miss Leon's section  Sign up at Reanimateconference.com.  Part 2 of this podcast includes the interview with Dr. Broman which will blow your mind.  So much great stuff in both of these interviews.]]>
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49 – You Can’t Spell REBOA without the ER – Endovascular Resuscitation of the Trauma Patient – Zaf Qasim https://edecmo.org/49-you-cant-spell-reboa-without-the-er-endovascular-resuscitation-of-the-trauma-patient-zaf-qasim/ Fri, 12 Oct 2018 14:27:38 +0000 https://edecmo.org/?p=4234 n this episode, Zack Shinar interviews Zaf Qasim about the recent controversies with ACEP and ACS about who can do REBOA.  Zaf is one of the world's experts on REBOA and he's an ER doc!  Zaf works at the University of Pennsylvania, trained in London as well as Shock Trauma in Baltimore and teaches at Reanimate.  When you come to the essence of this episode, the question is what is the emergency physician's role in the trauma resuscitation?  Both Zaf and Zack agree; we need to be the resuscitationist in the trauma suite.  We need to manage the airway and then quickly take over the arterial and venous access, interpret the transduced pressures, manage the massive transfusion protocol and be ready to insert the REBOA catheter while the trauma surgeon is involved with the left chest, the source of bleeding and where the next destination for this patient will be. n this episode, Zack Shinar interviews Zaf Qasim about the recent controversies with ACEP and ACS about who can do REBOA.  Zaf is one of the world's experts on REBOA and he's an ER doc!  Zaf works at the University of Pennsylvania, trained in London
In this episode, Zack Shinar interviews Zaf Qasim about the recent controversies with ACEP and ACS about who can do REBOA.  Zaf is one of the world's experts on REBOA and he's an ER doc!  Zaf works at the University of Pennsylvania, trained in London

as well as Shock Trauma in Baltimore and teaches at Reanimate.  When you come to the essence of this episode, the question is what is the emergency physician's role in the trauma resuscitation?  Both Zaf and Zack agree; we need to be the resuscitationist in the trauma suite.  We need to manage the airway and then quickly take over the arterial and venous access, interpret the transduced pressures, manage the massive transfusion protocol and be ready to insert the REBOA catheter while the trauma surgeon is involved with the left chest, the source of bleeding and where the next destination for this patient will be.]]>
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EDECMO 48: When Should I Transport a Cardiac Arrest? https://edecmo.org/edecmo-48-when-should-i-transport-a-cardiac-arrest/ Fri, 10 Aug 2018 12:14:51 +0000 https://edecmo.org/?p=4149 This part two of August 2018.  We are now tackling the difficult question of when to transport cardiac arrests if I have ECMO available?  Brian Grunau is an expert in this question.  Brian has become a giant in the world of ECMO.  His research, leadership and experience have pushed the Canadian ECPR contingency to the forefront.   Brian gives us some insight on what factors I should consider and when should I transport. This part two of August 2018.  We are now tackling the difficult question of when to transport cardiac arrests if I have ECMO available?  Brian Grunau is an expert in this question.  Brian has become a giant in the world of ECMO.  His research,

References



1.
Grunau B, Reynolds J, Scheuermeyer F, et al. Relationship between Time-to-ROSC and Survival in Out-of-hospital Cardiac Arrest ECPR Candidates: When is the Best Time to Consider Transport to Hospital? P. 2016;20(5):615-622. doi:10.3109/10903127.2016.1149652



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EDECMO 47: ECMO Donazione: Organ Transplantation with Velia Antonini https://edecmo.org/edecmo-47-ecmo-donazione-organ-transplantation-with-velia-antonini/ Sat, 04 Aug 2018 20:04:50 +0000 https://edecmo.org/?p=4139 Over this last year we have had episodes on organ donation and decision to transport.  This month we are revisiting two topics with two amazing people in two separate episodes.  Here, I interviewed Velia Marta Antonini.   Velia works in Italy where several of the great ECMO donation papers have originated.  She explains why this research is coming from Italy, what the process looks like, and the implications of this for other countries.  Check out her slides below. Over this last year we have had episodes on organ donation and decision to transport.  This month we are revisiting two topics with two amazing people in two separate episodes.  Here, I interviewed Velia Marta Antonini.
 





 

 

Here are Velia's slides on the subject

eisor ED ecmo (1)

 

 

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EDECMO 46: Wire Assistant https://edecmo.org/edecmo-46-wire-assistant/ Fri, 06 Jul 2018 02:21:25 +0000 https://edecmo.org/?p=4117 Well, it only took us seven years to figure this one out.  The wire assistant has been the key advancement of 2018 for placement of ECMO cannulas.  In this episode, Zack and Joe talk through this process after an  interview with Alyssa Baldini.  Alyssa was one of our first true wire assistants and has been instrumental in getting cannulas in faster and safer.  We discuss how the wire assistant aids in sterility and getting the artery on the first stick.  Bottom line - train someone at your shop to be an expert wire assistant. Well, it only took us seven years to figure this one out.  The wire assistant has been the key advancement of 2018 for placement of ECMO cannulas.  In this episode, Zack and Joe talk through this process after an  interview with Alyssa Baldini. the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 25:25 EDECMO 45: ECMO in Sepsis https://edecmo.org/edecmo-45-ecmo-for-sepsis/ Thu, 10 May 2018 23:12:25 +0000 https://edecmo.org/?p=4023 In this episode, Zack talks with Heidi Dalton about ECMO use in Sepsis.  This is another controversial area with pediatric literature showing strong results while the adult results have been less impressive.  Heidi has been a key figure in both adult and pediatric ECMO.  She is the former chair of the yearly ELSO conference.  She is a professor at both George Washington University and Virginia Commonwealth University.  Her background is in pediatric critical care. She currently works at INOVA in Virginia where she is the director of adult and pediatric ECMO. So the question for today is should we be utilizing ECMO for sepsis? In this episode, Zack talks with Heidi Dalton about ECMO use in Sepsis.  This is another controversial area with pediatric literature showing strong results while the adult results have been less impressive.
In this episode, Zack talks with Heidi Dalton about ECMO use in Sepsis.  This is another controversial area with pediatric literature showing strong results while the adult results have been less impressive.  Heidi has been a key figure in both adult and pediatric ECMO.  She is the former chair of the yearly ELSO conference.  She is a professor at both George Washington University and Virginia Commonwealth University.  Her background is in pediatric critical care. She currently works at INOVA in Virginia where she is the director of adult and pediatric ECMO.

Sepsis has been thought to be a contraindication to ECMO use secondary to the pro-inflammatory nature of ECMO and potential to harbor infection.  Recent research is certainly controversial with adult studies showing low survival in septic shock and sepsis as a cause of arrest.  As with much of ECMO literature, the problem is with the denominator – What is the expected survival of these patients?  The follow up question becomes what effort is prudent for these low survival rates?  The sepsis cohort tend to be younger and potential for long term survival is high.  The question remains should we be utilizing ECMO for sepsis?1–9
References



1.
Maclaren G, Butt W, Best D, Donath S, Taylor A. Extracorporeal membrane oxygenation for refractory septic shock in children: one institution’s experience. Pediatr Crit Care Med. 2007;8(5):447-451. [PubMed]




2.
Datzmann T, Träger K. Extracorporeal membrane oxygenation and cytokine adsorption. J. 2018;10(S5):S653-S660. doi:10.21037/jtd.2017.10.128




3.
Perdue SM, Poore BJ, Babu AN, Stribling WK. Successful use of extracorporeal membrane oxygenation support in severe septic shock with associated acute cardiomyopathy. J. 2018;33(1):50-52. doi:10.1111/jocs.13508




4.
von Bahr V, Hultman J, Eksborg S, Frenckner B, Kalzén H. Long-Term Survival in Adults Treated With Extracorporeal Membrane Oxygenation for Respiratory Failure and Sepsis*. C. 2017;45(2):164-170. doi:10.1097/ccm.0000000000002078




5.
Millar J, Fanning J, McDonald C, McAuley D, Fraser J. The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. Crit Care. 2016;20(1):387. [PubMed]




6.
Choi M, Ha S, Kim H, Park S, Han S, Lee S. The Simplified Acute Physiology Score II as a Predictor of Mortality in Patients Who Underwent Extracorporeal Membrane Oxygenation for Septic Shock. Ann Thorac Surg. 2017;103(4):1246-1253. [PubMed]




7.
Tramm R, Ilic D, Davies A, Pellegrino V, Romero L, Hodgson C. Extracorporeal membrane oxygenation for critically ill adults. Cochrane Database Syst Rev. 2015;1:CD010381. [PubMed]




8.
Park T, Yang J, Jeon K, et al. Extracorporeal membrane oxygenation for refractory septic shock in adults. Eur J Cardiothorac Surg. 2015;47(2):e68-74. [PubMed]
]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 31:02
EDECMO Crash Episode – Demetris Yannopoulos on ECPR-the Minneapolis Way https://edecmo.org/demetris-yannopoulos-on-ecpr-the-minneapolis-way/ Sun, 08 Apr 2018 18:49:11 +0000 https://edecmo.org/?p=3965 Yanno on ECPR Yanno on ECPR
We do an EDECMO ECPR course each year called REANIMATE. REANIMATE5 blew away all previous iterations. One of the main reasons was our guest of honor, Demetris Yannopoulos from the University of Minnesota. Demetris has organized Minneapolis into arguably the most impressive ECPR city in the world. We were lucky enough to be able to film his Sharp Hospital Grand Rounds. This lecture was mind-blowing and made us so jealous. We think you will love it.
Tickets are on Sale for REANIMATE6

* REANIMATEconference.com

Additional Info/Resources

* EDECMO 36 - Zack interviews Demetris
* EDECMO Crash Episode - Microdissection of Demetris' ECPR Techniques
* JAHA Publication on ECPR Results
* In-Depth Look at their Protocol [Resuscitation 2018;132:47


 ]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart 1:18:47
EDECMO 44: Bob Bartlett: Peristaltic Pumps, Hollow Fibers, and the History of ECMO https://edecmo.org/edecmo-44-bob-bartlett-peristaltic-pumps-hollow-fibers-history-ecmo/ Thu, 22 Mar 2018 00:12:26 +0000 https://edecmo.org/?p=3900 In this episode, Zack interviews Bob Bartlett from the University of Michigan.  He is truly the godfather of ECMO and has revolutionized the world with his leadership and innovation.  They discuss the history of ECMO and roller pumps and bubble oxygenators were clearly inferior to their current counterparts - centrifugal pumps and hollow fiber oxygenators.  They also discuss anticoagulation and how Bob feels direct thrombin inhibitors are superior.  They also discuss the future of ECMO and how peristaltic pumps may be where we are headed.   In this episode, Zack interviews Bob Bartlett from the University of Michigan.  He is truly the godfather of ECMO and has revolutionized the world with his leadership and innovation.  They discuss the history of ECMO and roller pumps and bubble oxygena...
In this episode, Zack Shinar interviews Dr. Bob Bartlett from the University of Michigan.  Dr. Bartlett has revolutionized the world with his leadership and innovation from the very beginnings of ECMO.  Zack and Bob discuss the history of ECMO and the prior use of roller pumps and bubble oxygenators.  They go on to describe the advantages of centrifugal pumps and hollow fiber oxygenators.  Additionally, they talk about PMP (polymethylpentene)-coated membranes inside oxygenators and their improved ability to safely oxygenate blood.  They discuss anticoagulation and how Bob believes that direct thrombin inhibitors are superior.  They wrap it up with a discussion on the future of ECMO and how peristaltic pumps have some significant advantages2.





3,4
References



1.
Perchinsky M, Long W, Hill J, Parsons J, Bennett J. Extracorporeal cardiopulmonary life support with heparin-bonded circuitry in the resuscitation of massively injured trauma patients. Am J Surg. 1995;169(5):488-491. [PubMed]




2.
Bartlett RH. Esperanza. A. 2017;63(6):832-843. doi:10.1097/mat.0000000000000697




3.
Ali AA, Downey P, Singh G, et al. Rat model of veno-arterial extracorporeal membrane oxygenation. J. 2014;12(1):37. doi:10.1186/1479-5876-12-37




4.
Spurlock DJ, Raney DN, Fracz EM, Mazur DE, Bartlet RH, Haft JW. In Vitro Testing of a Novel Blood Pump Designed for Temporary Extracorporeal Support. A. February 2012:1. doi:10.1097/mat.0b013e318245d356



]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 36:58
EDECMO 43: The Cutdown https://edecmo.org/edecmo-43-cutdown/ Tue, 20 Feb 2018 17:06:35 +0000 https://edecmo.org/?p=3781 In this episode,  Alice Hutin of the Paris SAMU talks about the modified cutdown approach to cannula insertion.  She is an emergency physician who is one of four physicians who take call on the pre-hospital ECMO ambulance.  She describes the process of their modified cutdown.  First, incision through the skin is made 2 cm below inguinal crease.  Second, blunt dissection down through the soft tissue.  This is best done with your fingers.  Third, place a needle through the distal skin and visualize it pass into the vessel.  From there, you cannulate as with percutaneous.  Alice’s recent paper shows a 6% failure rate with this technique in skilled hands. In this episode,  Alice Hutin of the Paris SAMU talks about the modified cutdown approach to cannula insertion.  She is an emergency physician who is one of four physicians who take call on the pre-hospital ECMO ambulance.
In this episode,  Alice Hutin of the Paris SAMU talks about the modified cutdown approach to cannula insertion.  She is an emergency physician who is one of four physicians who cannulates on the pre-hospital ECMO ambulance.  She describes the process of their modified cutdown.  We are holding off on written descriptions and pictures of the procedure pending Alice's publication so you will just have to listen!!!! We'll post the pictures soon!  Until then, here is a youtube segment showing a femoral cutdown -https://www.youtube.com/watch?v=zzu7cU3YoXo

 

Another recent publication by Alice:

Hutin A, Lamhaut L, Lidouren F, Kohlhauer M, Mongardon N, Carli P, Berdeaux A, Ghaleh B, Tissier R. Early Coronary Reperfusion Facilitates Return of Spontaneous Circulation and Improves Cardiovascular Outcomes After Ischemic Cardiac Arrest and Extracorporeal Resuscitation in Pigs. J Am Heart Assoc. 2016 Dec 22;5(12). pii: e004588. doi: 1. PubMed PMID: 28007740; PubMed Central PMCID: PMC5210433
References



1.
Hutin A, Lamhaut L, Lidouren F, et al. Early Coronary Reperfusion Facilitates Return of Spontaneous Circulation and Improves Cardiovascular Outcomes After Ischemic Cardiac Arrest and Extracorporeal Resuscitation in Pigs. J. 2016;5(12):e004588. doi:10.1161/jaha.116.004588



]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 29:49
EDECMO 42: Organ Transplantation On ECMO https://edecmo.org/edecmo-42-organ-transplantation-ecmo/ Tue, 16 Jan 2018 16:19:12 +0000 https://edecmo.org/?p=3746 In this episode, we tackle the subject of organ transplantation on ECMO.  2017 featured several articles showing the efficacy of ECMO for organ transplantation.  In Italy, 56% of total potential patients were successfully transplanted.  The success of these transplants have been comparable to patients not on ECMO.  Zack Shinar interviews Lionel Lamhaut, ECMO specialist from Paris, and Cyrus Olsen, ethicist from the University of Scranton, to dive into some of the deeper questions including financial implications, ethical angles, and research extrapolations.  Join Zack, Lionel and Cy at Big Sick 18 (bigsick18.org) in Zermatt Switzerland on February 7-9th,, 2018!!   1: Christopher DA, Woodside KJ. Expanding the Donor Pool: Organ Donation After Brain Death for Extracorporeal Membrane Oxygenation Patients. Crit Care Med. 2017 Oct;45(10):1790-1791. doi: 10.1097/CCM.0000000000002633. PubMed PMID: 28915178. 2: Bronchard R, Durand L, Legeai C, Cohen J, Guerrini P, Bastien O. Brain-Dead Donors on Extracorporeal Membrane Oxygenation. Crit Care Med. 2017 Oct;45(10):1734-1741. doi: 10.1097/CCM.0000000000002564. PubMed PMID: 28640022. 3: Casadio MC, Coppo A, Vargiolu A, Villa J, Rota M, Avalli L, Citerio G. Organ donation in cardiac arrest patients treated with extracorporeal CPR: A single centre observational study. Resuscitation. 2017 Sep;118:133-139. doi: 10.1016/j.resuscitation.2017.06.001. Epub 2017 Jun 12. PubMed PMID: 28596083. 4: Dalle Ave AL, Bernat JL. Donation after brain circulation determination of death. BMC Med Ethics. 2017 Feb 23;18(1):15. doi: 10.1186/s12910-017-0173-1. PubMed PMID: 28228145; PubMed Central PMCID: PMC5322624. 5: Larsson M, Forsman P, Hedenqvist P, Östlund A, Hultman J, Wikman A, Riddez L, Frenckner B, Bottai M, Wahlgren CM. Extracorporeal membrane oxygenation improves coagulopathy in an experimental traumatic hemorrhagic model. Eur J Trauma Emerg Surg. 2017 Oct;43(5):701-709. doi: 10.1007/s00068-016-0730-1. Epub 2016 Nov 4. PubMed PMID: 27815579; PubMed Central PMCID: PMC5629226. 6: Dalle Ave AL, Shaw DM, Gardiner D. Extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation or uncontrolled donation after the circulatory determination of death following out-of-hospital refractory cardiac arrest-An ethical analysis of an unresolved clinical dilemma. Resuscitation. 2016 Nov;108:87-94. doi: 10.1016/j.resuscitation.2016.07.003. Epub 2016 Jul 20. Review. PubMed PMID: 27449821. 7: Fan X, Chen Z, Nasralla D, Zeng X, Yang J, Ye S, Zhang Y, Peng G, Wang Y, Ye Q. The organ preservation and enhancement of donation success ratio effect of extracorporeal membrane oxygenation in circulatory unstable brain death donor. Clin Transplant. 2016 Oct;30(10):1306-1313. doi: 10.1111/ctr.12823. Epub 2016 Sep 5. PubMed PMID: 27460305. 8: Jasseron C, Lebreton G, Cantrelle C, Legeai C, Leprince P, Flecher E, Sirinelli A, Bastien O, Dorent R. Impact of Heart Transplantation on Survival in Patients on Venoarterial Extracorporeal Membrane Oxygenation at Listing in France. Transplantation. 2016 Sep;100(9):1979-87. doi: 10.1097/TP.0000000000001265. PubMed PMID: 27306536. 9: Migliaccio ML, Zagli G, Cianchi G, Lazzeri C, Bonizzoli M, Cecchi A, Anichini V, Gensini GF, Peris A. Extracorporeal membrane oxygenation in brain-death organ and tissues donors: a single-centre experience. Br J Anaesth. 2013 Oct;111(4):673-4. doi: 10.1093/bja/aet323. PubMed PMID: 24027145. In this episode, we tackle the subject of organ transplantation on ECMO.  2017 featured several articles showing the efficacy of ECMO for organ transplantation.  In Italy, 56% of total potential patients were successfully transplanted.


In this episode, we tackle the subject of organ transplantation on ECMO.  2017 featured several articles showing the efficacy of ECMO for organ transplantation.  In Italy, 56% of total potential patients were successfully transplanted.  The success of these transplants have been comparable to patients not on ECMO.  Zack Shinar interviews Lionel Lamhaut, ECMO specialist from Paris, and Cyrus Olsen, ethicist from the University of Scranton, to dive into some of the deeper questions including financial implications, ethical angles, and research extrapolations.  Join Zack, Lionel and Cy at Big Sick 18 (bigsick18.org) in Zermatt Switzerland on February 7-9th,, 2018!!

 

1: Christopher DA, Woodside KJ. Expanding the Donor Pool: Organ Donation After
Brain Death for Extracorporeal Membrane Oxygenation Patients. Crit Care Med. 2017
Oct;45(10):1790-1791. doi: 10.1097/CCM.0000000000002633. PubMed PMID: 28915178.

2: Bronchard R, Durand L, Legeai C, Cohen J, Guerrini P, Bastien O. Brain-Dead
Donors on Extracorporeal Membrane Oxygenation. Crit Care Med. 2017
Oct;45(10):1734-1741. doi: 10.1097/CCM.0000000000002564. PubMed PMID: 28640022.

3: Casadio MC, Coppo A, Vargiolu A, Villa J, Rota M, Avalli L, Citerio G. Organ
donation in cardiac arrest patients treated with extracorporeal CPR: A single
centre observational study. Resuscitation. 2017 Sep;118:133-139. doi:
10.1016/j.resuscitation.2017.06.001. Epub 2017 Jun 12. PubMed PMID: 28596083.

4: Dalle Ave AL, Bernat JL. Donation after brain circulation determination of
death. BMC Med Ethics. 2017 Feb 23;18(1):15. doi: 10.1186/s12910-017-0173-1.
PubMed PMID: 28228145; PubMed Central PMCID: PMC5322624.

5: Larsson M, Forsman P, Hedenqvist P, Östlund A, Hultman J, Wikman A, Riddez L,
Frenckner B, Bottai M, Wahlgren CM. Extracorporeal membrane oxygenation improves
coagulopathy in an experimental traumatic hemorrhagic model. Eur J Trauma Emerg
Surg. 2017 Oct;43(5):701-709. doi: 10.1007/s00068-016-0730-1. Epub 2016 Nov 4.
PubMed PMID: 27815579; PubMed Central PMCID: PMC5629226.

6: Dalle Ave AL, Shaw DM, Gardiner D. Extracorporeal membrane oxygenation (ECMO)
assisted cardiopulmonary resuscitation or uncontrolled donation after the
circulatory determination of death following out-of-hospital refractory cardiac
arrest-An ethical analysis of an unresolved clinical dilemma. Resuscitation. 2016
Nov;108:87-94. doi: 10.1016/j.resuscitation.2016.07.003. Epub 2016 Jul 20.
Review. PubMed PMID: 27449821.

7: Fan X, Chen Z, Nasralla D, Zeng X, Yang J, Ye S, Zhang Y, Peng G, Wang Y, Ye
Q. The organ preservation and enhancement of donation success ratio effect of
extracorporeal membrane oxygenation in circulatory unstable brain death donor.
Clin Transplant. 2016 Oct;30(10):1306-1313. doi: 10.1111/ctr.12823. Epub 2016 Sep
5. PubMed PMID: 27460305.

8: Jasseron C, Lebreton G, Cantrelle C, Legeai C, Leprince P, Flecher E,
Sirinelli A, Bastien O, Dorent R. Impact of Heart Transplantation on Survival in
Patients on Venoarterial Extracorporeal Membrane Oxygenation at Listing in
France. Transplantation. 2016 Sep;100(9):1979-87. doi:
10.1097/TP.0000000000001265. PubMed PMID: 27306536.

9: Migliaccio ML, Zagli G, Cianchi G, Lazzeri C, Bonizzoli M, Cecchi A, Anichini
V, Gensini GF, Peris A. Extracorporeal membrane oxygenation in brain-death organ
and tissues donors: a single-centre experience. Br J Anaesth. 2013
Oct;111(4):673-4. doi: 10.1093/bja/aet323. PubMed PMID: 24027145.]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 32:07
EDECMO 41 – The 3 Stages of ECPR – Diane’s Story https://edecmo.org/edecmo-41-3-stages-ecpr-dianes-story-2/ Sat, 30 Dec 2017 02:04:15 +0000 https://edecmo.org/?p=3711 In this episode Zack and Joe discuss the 3-stages of Extracorporeal Membrane Oxygenation (ECMO) - or put another way, this is how to start Extracorporeal Cardiopulmonary Resuscitation (ECPR) in the Emergency Department (ED). It's been 4 years since we talked about these basic premises of ECPR. But this time, its highlighted in a very special story. In this episode Zack and Joe discuss the 3-stages of Extracorporeal Membrane Oxygenation (ECMO) - or put another way, this is how to start Extracorporeal Cardiopulmonary Resuscitation (ECPR) in the Emergency Department (ED).
In this episode Zack and Joe discuss the 3-stages of Extracorporeal Membrane Oxygenation (ECMO) - or put another way, this is how to start Extracorporeal Cardiopulmonary Resuscitation (ECPR) in the Emergency Department (ED). It's been 4 years since we talked about these basic premises of ECPR. But this time, its highlighted in a very special story.

The Three Stages of ECPR:

* Placement of any commercially available catheters into the femoral artery and femoral vein.

* Ultrasound-guided percutaneous access is our preference, but cutdown is also considered.  This is done in every patient, every time, and is done in parallel to ongoing ACLS. Transduce the arterial line to guide resuscitation and use the venous line for resuscitation purposes.


* Transition to ECMO cannulas

* Using guidewires (we prefer the Amplatz Super Stiff 145 cm .038" teflon coated floppy tip wires), remove the catheters placed in Stage 1, perform serial dilation, and place ECMO cannulas


* Initiate the ECMO pump

* Perform 'underwater seal' using crystalloid, which closes the circuit.  The circuit is de-aired and the pump is started.  Increase the RPM to 1500 and remove the clamps.  Inspect the circuit and troubleshoot any issues.



3 stages. 3 steps.

You can find a whole lot more on our ECPR 3 stages page.

EVEN BETTER! If you are interested in learning all about ED ECMO, with hands-on simulators, Wold-renowned ECMO educators, REBOA, ECPR, computer simulation, check out the REANIMATE conference site or go directly to the REANIMATE registration page!!

 

Diane's Story:

November 30, 2017: Diane suffered ventricular fibrillation (VF) cardiac arrest and collapsed...just outside the ED doors.  CPR was started immediately by an ED nurse. After 32 minutes of failed Advanced Cardiac Life Support (ACLS), with human and mechanical chest compressions, she remained in refractory VF.

Our Emergency Physician-initiated ECMO (ED-ECMO) protocol was initiated using the '3 stages of ECMO.'   Diane was 'on pump' in 32 minutes, taken to the cath lab, and had her 95% LAD lesion stented by Interventional Cardiologist Arvin Narula.

Diane went home with her family and friends on December 13, 2017.  Listen to the episode to hear the details...

Diane's Widowmaker

 

 

Dr. Narula, Interventional Cardiology



Joe and Diane

Diane with Casey Gwynn and sister Joanne

Dr. Eads and Diane

Zack Shinar, Diane, and Jessica

Bellezzo And Diane]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 30:32
EDECMO 40: EROCA – The trial that asks “Should ER Docs Initiate ECPR?” https://edecmo.org/eroca-trial-asks-er-docs-initiate-ecpr/ Thu, 02 Nov 2017 20:00:55 +0000 https://edecmo.org/?p=3602   EROCA - University of Michigan - Gunnerson/Shinar Should Emergency Physicians initiate ECMO on arresting patients?  That is the question that Kyle Gunnerson from the University of Michigan (UMich) is asking with their new trial - EROCA.  UMich has had a robust ECMO program for over 30 years and recently they have received a grant to fund an out of hospital cardiac arrest protocol for emergency physician initiated ECPR.  In this episode, Zack asks Kyle how this trial is being undertaken with key side points on how to start a program, how to train the personnel, and how to circumnavigate the many roadblocks we commonly face in the development of an ECMO program.  They talk about the limitations of running a trial with physicians with no prior experience in ECPR initiation as well as the novel resuscitation strategies that UMich is deploying in all of their cardiac arrest patients.     - EROCA - University of Michigan - Gunnerson/Shinar - Should Emergency Physicians initiate ECMO on arresting patients?  That is the question that Kyle Gunnerson from the University of Michigan (UMich) is asking with their new trial - EROCA.


 

EROCA - University of Michigan - Gunnerson/Shinar

Should Emergency Physicians initiate ECMO on arresting patients?  That is the question that Kyle Gunnerson from the University of Michigan (UMich) is asking with their new trial - EROCA.  UMich has had a robust ECMO program for over 30 years and recently they have received a grant to fund an out of hospital cardiac arrest protocol for emergency physician initiated ECPR.  In this episode, Zack asks Kyle how this trial is being undertaken with key side points on how to start a program, how to train the personnel, and how to circumnavigate the many roadblocks we commonly face in the development of an ECMO program.  They talk about the limitations of running a trial with physicians with no prior experience in ECPR initiation as well as the novel resuscitation strategies that UMich is deploying in all of their cardiac arrest patients.

 

]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 28:36
EDECMO 39: Who Do We Put On ECMO? – New Data on Prognostics https://edecmo.org/edecmo-39-put-ecmo-new-data-prognostics/ Fri, 06 Oct 2017 04:43:54 +0000 https://edecmo.org/?p=3534 In this episode Zack interviews the first authors of the three biggest papers this year dealing with the question of “Who should I put on ECMO?”  Guillaume Debaty of Grenoble, France published a paper outlining what prognostic factors are important.  Guillaume's data shows importance of short low times, lower lactates and higher pH values.  The real question is what number for each of these should we consider a hard stop on initiation.  This is followed up by Josh Reynolds who along with Ben Singer out of the UK published a paper utilizing cardiac arrest data from the PRIMED trial.  He showed that even patients with all the advantageous characteristics of traditional ECMO inclusion criteria had poor survivals once they have had >30 minutes of chest compressions.  With many ECMO studies having average arrest to initiation times of > 60 minutes, Josh’s paper certainly makes us view favorably the 30% survival outcomes that we are seeing worldwide.  This in no way substitutes for a randomized trial but does offer some guidance on what the expected survival of a patient with a witnessed arrest, short low flow times, and age < 65.   We  conclude with Nate Haas out of the University of Michigan who utilitzed the ELSO database to show that age was not predictive of survival.  This may push us towards including older patients in our inclusion criteria, but more data is definitely needed on this. In this episode Zack interviews the first authors of the three biggest papers this year dealing with the question of “Who should I put on ECMO?”  Guillaume Debaty of Grenoble, France published a paper outlining what prognostic factors are important.
In this episode Zack interviews the first authors of the three biggest papers this year dealing with the question of “Who should I put on ECMO?”  Guillaume Debaty of Grenoble, France published a paper outlining what prognostic factors are important.  Guillaume's data shows importance of short low times, lower lactates and higher pH values.  The real question is what number for each of these should we consider a hard stop on initiation.  This is followed up by Josh Reynolds who along with Ben Singer out of the UK published a paper utilizing cardiac arrest data from the PRIMED trial.  He showed that even patients with all the advantageous characteristics of traditional ECMO inclusion criteria had poor survivals once they have had >30 minutes of chest compressions.  With many ECMO studies having average arrest to

initiation times of > 60 minutes, Josh’s paper certainly makes us view favorably the 30% survival outcomes that we are seeing worldwide.  This in no way substitutes for a randomized trial but does offer some guidance on what the expected survival of a patient with a witnessed arrest, short low flow times, and age < 65.   We  conclude with Nate Haas out of the University of Michigan who utilitzed the ELSO database to show that age was not predictive of survival.  This may push us towards including older patients in our inclusion criteria, but more data is definitely needed on this.

 

Bibliography:

1: Haas NL, Coute RA, Hsu CH, Cranford JA, Neumar RW. Descriptive analysis of
extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac
arrest-An ELSO registry study
. Resuscitation. 2017 Oct;119:56-62. doi:
10.1016/j.resuscitation.2017.08.003. Epub 2017 Aug 5. PubMed PMID: 1.

 

2: Reynolds JC, Grunau BE, Elmer J, Rittenberger JC, Sawyer KN, Kurz MC, Singer
B, Proudfoot A, Callaway CW. Prevalence, natural history, and time-dependent
outcomes of a multi-center North American cohort of out-of-hospital cardiac
arrest extracorporeal CPR candidates. Resuscitation. 2017 Aug;117:24-31. doi:
10.1016/j.resuscitation.2017.05.024. Epub 2017 May 25. PubMed PMID: 2.

 

3: Debaty G, Babaz V, Durand M, Gaide-Chevronnay L, Fournel E, Blancher M,
Bouvaist H, Chavanon O, Maignan M, Bouzat P, Albaladejo P, Labarère J. Prognostic
factors for extracorporeal cardiopulmonary resuscitation recipients following
out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis.
Resuscitation. 2017 Mar;112:1-10. doi: 10.1016/j.resuscitation.2016.12.011. Epub
2016 Dec 19. Review. PubMed PMID: 3.

References



1.
Haas N, Coute R, Hsu C, Cranford J, Neumar R. Descriptive analysis of extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest-An ELSO registry study
. Resuscitation. 2017;119:56-62. [PubMed]




2.
Reynolds J, Grunau B, Elmer J, et al. Prevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates. Resuscitation. 2017;117:24-31. [PubMed]




3.
Debaty G, Babaz V, Durand M, et al. Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis. Resuscitation. 2017;112:1-10. [PubMed]



]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 36:15
Crash Episode: Iowa OHCA ECMO Save – with Andrew Karl Terry https://edecmo.org/crash-episode-iowa-ohca-ecmo-save-andrew-karl-terry/ Thu, 07 Sep 2017 05:20:54 +0000 https://edecmo.org/?p=3421 Mini episode - This is a great example of where a little persistence with your colleagues can help save someone's life.  Dr. Andrew Karl Terry, having had only limited exposure to ECMO, was able to encourage his Cardiologists to put a witnessed VF patient on ECMO.  The rest is history! Mini episode - This is a great example of where a little persistence with your colleagues can help save someone's life.  Dr. Andrew Karl Terry, having had only limited exposure to ECMO, was able to encourage his Cardiologists to put a witnessed VF pati...
Crash Episode - This is a great example of where a little persistence with your colleagues can help save someone's life.  Dr. Andrew Karl Terry, having had only limited exposure to ECMO, was able to encourage his Cardiologists to put a witnessed VF patient on ECMO.  The rest is history!]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 11:12
EDECMO 38 – ECMO and Trauma – with Pal Ager-Wick and Magnus Larsson https://edecmo.org/edecmo-38-ecmo-trauma-pal-ager-wick-magnus-larsson/ Mon, 28 Aug 2017 00:13:54 +0000 https://edecmo.org/?p=3355 This episode is all about ECMO in trauma - not the usual ARDS, TRALI VV-ECMO - we’re talking about VA ECMO for the acutely dying trauma patient. Zack interviews Pål Ager-Wick from Tromso Norway, and Magnus Larsson from the Karolinska Institute in Stockholm. We talk about everything from how ECMO helps the hemorrhaging trauma patient to the futuristic “Emergency Preservation and Resuscitation” concept being done in Baltimore now. This episode is all about ECMO in trauma - not the usual ARDS, TRALI VV-ECMO - we’re talking about VA ECMO for the acutely dying trauma patient. Zack interviews Pål Ager-Wick from Tromso Norway, and Magnus Larsson from the Karolinska Institute in Stock... This episode is all about ECMO in trauma - not the usual ARDS, TRALI VV-ECMO - we’re talking about VA ECMO for the acutely dying trauma patient. Zack interviews Pål Ager-Wick from Tromso Norway, and Magnus Larsson from the Karolinska Institute in Stockholm. We talk about everything from how ECMO helps the hemorrhaging trauma patient to the futuristic “Emergency Preservation and Resuscitation” concept being done in Baltimore now.

Photo used with permission of SAMU of Paris



Bullet Points:

* VV ECMO –

* Marginal data suggests ECMO beneficial in ARDS (CESAR, ANZECMO trials)
* ARDS and TRALI in trauma is a reasonable extension of this


* Damage Control Surgery –

* focus on coagulation
* stop major bleeders and then take to ICU
* lethal triad of coagulation includes hypothermia, dilution of coagulation factors and acidosis


* Coagulation of trauma: ECMO can improve all three components of lethal triad
* Heparin has been successfully withheld in bleeding trauma patients
* ECMO in Severe Chest Trauma – 10 patients, 8 ruptured cardiac chambers1
* Blunt cardiac arrest – a case report2
* Bleeding less than 15% mortality after 1995, Intracranial hemorrhage patients can survive. In fact none of the ICH patients on ECMO who died died of brain bleeding (60-93% survived). Survival was 42-63% for VA ECMO. Lower ACT (<180 sec)3
* ELSO – VA ECMO in trauma – 45% survival4
* ECMO reduces venous pressure which may be beneficial in hemorrhaging patients5
* Tisherman – Suspended Animation: Emergency Preservation and Resuscitation678

Magnus Larsson


References



1.
Huh U, Song S, Chung S, et al. Is Extracorporeal Cardiopulmonary Resuscitation Practical in Severe Chest Trauma? : A Systematic Review in Single Center of Developing Country. J Trauma Acute Care Surg. August 2017. [PubMed]




2.
Kudo S, Tanaka K, Okada K, Takemura T. Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture: A case report. Am J Emerg Med. August 2017. [PubMed]




3.
Bedeir K, Seethala R, Kelly E. Extracorporeal life support in trauma: Worth the risks? A systematic review of published series. J Trauma Acute Care Surg. 2017;82(2):400-406. [PubMed]




4.
ELSO Registry. Extracoporeal Life Support Organization. http://www.elso.org/Registry/Statistics/InternationalSummary.aspx.




5.
Larsson M, Talving P, Palmér K, Frenckner B, Riddez L, Broomé M. Experimental extracorporeal membrane oxygenation reduces central venous pressure: an adjunct to control of venous hemorrhage? Perfusion. 2010;25(4):217-223. [PubMed]




6.
Tisherman S, Safar P, Radovsky A, Peitzman A, Sterz F, Kuboyama K. Therapeutic deep hypothermic circulatory arrest in dogs: a resuscitation modality for hemorrhagic shock with “irreparable” injury. J Trauma. 1990;30(7):836-847. [ clean 31:34
EDECMO 37 – Nate’s Story https://edecmo.org/edecmo-37-what-if-you-had-to-put-your-own-dying-child-on-ecmo/ Fri, 21 Jul 2017 18:20:53 +0000 https://edecmo.org/?p=3260 Jake is an Emergency Physician from Santa Cruz California whose interest in resuscitation was put to the fullest test when his own son had a cardiac arrest. This is the amazing retelling of that day in November when what Jake learned in an EDECMO workshop was utilized in a dramatic fashion. This is a story of two heros: Jake and his son Nate. Jake is an Emergency Physician from Santa Cruz California whose interest in resuscitation was put to the fullest test when his own son had a cardiac arrest. This is the amazing retelling of that day in November when what Jake learned in an EDECMO works... the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 32:38 Crash Episode – MicroDissection of Yannopoulos’ ECMO Method https://edecmo.org/crash-episode-microdissection-yannopoulos-ecmo-method/ Sat, 15 Jul 2017 20:50:46 +0000 https://edecmo.org/?p=3256 The University of Minnesota Cath Lab Cannulation Method The University of Minnesota Cath Lab Cannulation Method Zack interviewed Demetris Yannopoulos on the amazing ECPR experience at University of Minnesota. In this crash episode, I reinterview Dr. Yannopoulos on the intricacies of how cannulates.
Some Highlights

* Uses amplatz super-stiff with 1cm J-tip
* arterial puncture first
* dilates with 12 and 14 for artery and 16 and 18 for vein
* places venous cannula first
* 25 F venous cannula
* places arterial 15 F in females and 17 F in males empirically (different than publication)
* Dilates tracts with kelly
* Starts flow at 2.5 50% fio2 and ramps up
* His leg perfusion cath of choice is the 9F Arrow Mac. He uses the big sideport for blood flow and the smaller one to run the systemic heparin

 

 

 ]]> the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 35:41 EDECMO 36 – Crushing the Nihilism of Cardiac Arrest – with Demetris Yannopoulos https://edecmo.org/edecmo-36-crushing-nihilism-cardiac-arrest-demetri-yannopoulos/ Fri, 09 Jun 2017 22:40:23 +0000 https://edecmo.org/?p=3210 In this podcast episode, Zack interviews Demetri Yannopoulos from the University of Minnesota. Demetri has organized Minneapolis into arguably the most impressive ECPR city in the world. He has changed the mindset of out of hospital refractory ventricular fibrillation care from “stay and play”, the philosophy that medics should stay at the scene and provide care until ROSC (return of spontaneous circulation) or until the patient is pronounced dead. In Minneapolis, a patient who who arrests in  Yannopoulos’ catchment area gets three shocks. If the patient does not get ROSC then they are immediately transported to the University of Minnesota using LUCAS mechanical chest compression device. The patient bypasses the emergency department and goes directly to the cath lab. In the cath lab, Demetri, or one of his partners, cannulates and initiates ECMO with an average time of 6 minutes!!! In his first 90 patients he has had a 45% neurologically intact survivorship. Patients are getting to the cath lab on average 60 minutes after their arrest. In this cohort, you would expect a less than 1% survival. We can use Dr. Yannopoulos’ model to expand the use of ECPR in many other systems. The real question is do we have champions like Demetri who will rise to the calling! In this podcast episode, Zack interviews Demetri Yannopoulos from the University of Minnesota. Demetri has organized Minneapolis into arguably the most impressive ECPR city in the world. He has changed the mindset of out of hospital refractory ventricu...  

Demetris YannapoulosUniversity of Minnesota

In this podcast episode, Zack interviews Demetris Yannopoulos from the University of Minnesota. Demetris has organized Minneapolis into arguably the most impressive ECPR city in the world. He has changed the mindset of out of hospital refractory ventricular fibrillation care from “stay and play”, the philosophy that medics should stay at the scene and provide care until ROSC (return of spontaneous circulation) or until the patient is pronounced dead. In Minneapolis, a patient who who arrests in  Yannopoulos’ catchment area gets three shocks. If the patient does not get ROSC then they are immediately transported to the University of Minnesota using LUCAS mechanical chest compression device. The patient bypasses the emergency department and goes directly to the cath lab. In the cath lab, Demetris, or one of his partners, cannulates and initiates ECMO with an average time of 6 minutes!!! In his first 90 patients he has had a 45% neurologically intact survivorship. Patients are getting to the cath lab on average 60 minutes after their arrest. In this cohort, you would expect a less than 1% survival. We can use Dr. Yannopoulos’ model to expand the use of ECPR in many other systems. The real question is do we have champions like Demetris who will rise to the calling!

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EDECMO 35 – REBOA REVISITED! https://edecmo.org/edecmo-35-reboa-revisited/ Fri, 07 Apr 2017 19:29:09 +0000 https://edecmo.org/?p=3129 REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is used to gain proximal control over non-compressible hemorrhage below the diaphragm. In this episode, Zack takes a deep dive into REBOA implementation, physiology, and complications with four of the biggest movers in the world of REBOA: REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is used to gain proximal control over non-compressible hemorrhage below the diaphragm. In this episode, Zack takes a deep dive into REBOA implementation, physiology,
Weingart did a wonderful job describing REBOA using the 12F Chek-Flo and CODA catheter here:

https://emcrit.org/podcasts/reboa/

Our good friend Rob Orman from ERCAST.org and EMRAP interviewed Zaf Qasim:

http://blog.ercast.org/reboa/

And Weingart revisited REBOA, spoke with Joe DuBose, and described the newest REBOA catheter, the PryTime 7F ER REBOA catheter that most of us now use:

https://emcrit.org/podcasts/er-reboa/

 

...So we aren't going to rehash any of that stuff in this episode!

In this episode, Zack takes a deep dive into REBOA implementation, physiology, and complications with four of the biggest movers in the world of REBOA:

Dr. David Callaway Military Trauma Specialist

Dr. David Callaway is an Emergency Physician from the Carolinas Health System, who also serves on the Defense Health Board Subcommittee on Trauma and Injury as well as the Committee on Tactical Combat Casualty Care- two of the key U.S. advisory bodies for battlefield trauma care. He is the Co- Chairman of the Committee for Tactical Emergency Casualty Care, a best practices R&D group charged with translating battlefield lessons learned to civilian high threat prehospital medicine.

Dr. Callaway describes how they implement REBOA  in their busy trauma unit and some of the data behind its use.



 

Dr. Tatuya Norii University of New Mexico

But REBOA is not without controversy.  So Zack turned to Dr. Tatsuyo Norii, from the University of New Mexico, who published a study that showed that REBOA may result in increased mortality in certain patients.1 Dr. Norii believes that we should avoid REBOA in patients with traumatic brain injury and patients with multi-system trauma.

Shinar and Dr. Norii also discussed how REBOA may also be considered  non-trauma situations where patients are bleeding to death:  ruptured ectopic pregnancy, postpartum hemorrhage, ruptured abdominal aneurysm, and perhaps some patients with hemorrhagic gastrointestinal bleeding.

 



Austin Johnson MD PhD UC Davis

Then,  Zack turned to Dr. Austin Johnson from UC Davis.  They do  a deep dive into the physiology of of a patient on REBOA and its nuances in traumatic brain injury.

And lastly, They discussed the concept of partial REBOA (P-REBOA) and the concept of "windsocking". As the balloon size is decreased by decreasing the volumes within it, the flow around the balloon is not linear. This becomes increasingly important as we consider 'partial REBOA', prolonged occlusion, and balloon takedown, a topic published by Dr. Johnson a few months ago.2

 



Zaf Qasim MD REBOA guru

Finally, we wrap things up with a discussion with Zaf Qasim,]]>
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EDECMO 34 – The Day After REANIMATE – with Dr. Sean Deitch https://edecmo.org/edecmo-34-day-reanimate-dr-sean-deitch/ Wed, 15 Mar 2017 20:07:21 +0000 https://edecmo.org/?p=3090 In this episode, Joe talks with Dr. Sean Deitch, a non-academic Emergency Physician practicing in San Diego, California. Dr. Deitch attended REANIMATE 3 - which just finished 2 weeks ago...and has an amazing story to tell. You'll have to listen to the episode... REANIMATE 4 is September 21-22, 2017 and features guest faculty member Stephen Bernard - coming all the way from Melbourne, Australia - and best know from the original therapeutic hypothermia trials and CHEER. R3 was amazing and R4 will be even better!! In this episode, Joe talks with Dr. Sean Deitch, a non-academic Emergency Physician practicing in San Diego, California. Dr. Deitch attended REANIMATE 3 - which just finished 2 weeks ago...and has an amazing story to tell. In this episode, Joe talks with Dr. Sean Deitch, a non-academic Emergency Physician practicing in San Diego, California.  Dr. Deitch attended REANIMATE 3 - which just finished 2 weeks ago...and has an amazing story to tell.  You'll have to listen to the episode...

REANIMATE 4 is September 21-22, 2017 and features guest faculty member Stephen Bernard - coming all the way from Melbourne, Australia - and best know from the original therapeutic hypothermia trials and CHEER.  R3 was amazing and R4 will be even better!!

To register for REANIMATE 4: www.reanimateconference.com/register

 ]]>
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EDECMO 33a – “Bringing Down the House” by Zack Shinar (from RESUSfest 2016) https://edecmo.org/edecmo-33a-bringing-house-zack-shinar-resusfest-2016/ Thu, 26 Jan 2017 07:49:55 +0000 https://edecmo.org/?p=2970 In this episode of the EDECMO podcast, Zack describes how to use the concept of 'TEAM PLAY", much like the gang from the classic novel "Bringing Down the House" by Ben Mezrich, to optimize outcomes after cardiac arrest....with, or without, ECPR. In this episode of the EDECMO podcast, Zack describes how to use the concept of 'TEAM PLAY", much like the gang from the classic novel "Bringing Down the House" by Ben Mezrich, to optimize outcomes after cardiac arrest....with, or without, ECPR. "Bringing Down the House" by Ben Mezrich, to optimize outcomes after cardiac arrest....with, or without, ECPR.

Zack's tips for running a code:

* Proper, high-quality CPR
* The choreography of running a code
* Let your nurses run the code
* CPR Alfresco (transitioning the patient from EMS gurney to hospital gurney IN THE AMBULANCE BAY)

Upcoming EVENTS:
REANIMATE 3 Conference: March 2-3, 2017 (sold out! but click the link to go to the wait list)

REANIMATE 4 Conference: September 21-22, 2017  (registration will open on March 21, 2017. Add your name to the REANIMATE wait list for first chance at R4 tickets)

Castlefest 2017: April 10-14, 2017

Resusfest 2017: April 13-14, 2017

Essentials of Emergency Medicine 2017 at the Cosmopolitan Hotel in Las Vegas, Nevada: May 16-18, 2017

 
Bringing Down the House:
 

]]>
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EDECMO 32 – Archimedes Screw: Is Impella the Future of Mechanical Circulatory Support? https://edecmo.org/edecmo-32-archimedes-screw-impella-future-mechanical-circulatory-support/ Wed, 07 Dec 2016 00:34:12 +0000 https://edecmo.org/?p=2890 In this episode we explore two very different applications of the Impella® device - a percutaneously-placed temporary ventricular assist device (VAD) sold by Abiomed (no financial disclosures). These VADs work by the use of a micro-axillary pump which is typically placed by interventional cardiologists under fluoroscopy. The inlet of the pump is placed in the ventrical while the outlet rests just above the aortic valve. In this episode we explore two very different applications of the Impella® device - a percutaneously-placed temporary ventricular assist device (VAD) sold by Abiomed (no financial disclosures). These VADs work by the use of a micro-axillary pump which ... Abiomed (no financial disclosures). These VADs work by the use of a micro-axillary pump which is typically placed by interventional cardiologists under fluoroscopy. The inlet of the pump is placed in the ventrical while the outlet rests just above the aortic valve.  Take a look at this video for a  better understanding of how this works:



Guests on this show:

Jenelle Badulak MD Critical Care Fellow University of Washington

Dr. Henrik Vase Interventional Cardiologist Aarhus University Hospital, Denmark

 

 

]]>
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EDECMO 31 – Anaphylaxis & Epi-Pens. Are we ready for VV-ECMO in the Emergency Department? https://edecmo.org/edecmo-31-anaphylaxis-epi-pens-ready-vv-ecmo-emergency-department/ Tue, 11 Oct 2016 19:14:17 +0000 https://edecmo.org/?p=2783 Here is a case of a young man who presented to the Emergency Department with profound anaphylaxis. This was a "CAN Intubate/CAN'T VENTILATE" scenario: Max Epinephrine Max antihistamines Max steroids Max ventilator What options do you have? Find out in this episode. Here is a case of a young man who presented to the Emergency Department with profound anaphylaxis. This was a "CAN Intubate/CAN'T VENTILATE" scenario: - Max Epinephrine Max antihistamines Max steroids Max ventilator What options do you have? 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:

* Max Epinephrine
* Max antihistamines
* Max steroids
* Max ventilator

...and you still cannot ventilate.  PaCO2 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 MDIntensive CareSharp Memorial Hospital

Andrew Eads MDEmergency MedicineSharp Memorial Hospital

Melissa Brunsvold MD Department of Surgery University of Minnesota

Conrad Soriano

Brynn ShinarCutest Girl on Earth]]>
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EDECMO 30 – Post-Arrest ECMO Critical Care Management with Deirdre Murphy https://edecmo.org/post-arrest-ecmo-critical-care-management-deirdre-murphy/ Fri, 09 Sep 2016 18:04:18 +0000 https://edecmo.org/?p=2516 Post Pump Crit Care Post Pump Crit Care
The Alfred has put itself on the map in so many ways over the past decade. Home to Stephen Bernard (of the original Hypothermia after ROSC without RONF fame), Chris Nickson (@precordialthump, @ragepodcast, @intensiveblog, #SMACC, lifeinthefastlane.com), and good friends Jason McClure, Steve McGloughlin, Josh Ihle, Paul Nixon, and Deirdre Murphy, The Alfred is becoming a mecca for advanced resuscitation and ECMO/ECPR.  In this episode we sat down with Dr. Murphy to discuss the nuances of weaning a patient from ECMO.



Deirdre Murphy


Deirdre Murphy MB (Hons), MRCPI, FCARCSI, FCICM, DDU (Crit Care), PGDipEcho

Deirdre is Deputy Director ICU, Director of the Cardiothoracic ICU at The Alfred Hospital with particular interests in echocardiography and cardiac intensive care, especially mechanical circulatory supports including Ventricular Assist Devices and ECMO. Deirdre originally trained in Ireland with postgraduate training in general medicine and anaesthesia prior to undertaking intensive care training in Australia in 1999. She has been an Intensivist at The Alfred since 2003. Deirdre has been using echo in clinical practice since 2002 and heads the ICU echocardiography programme at the Alfred. She is convenor of the Alfred Critical Care Echocardiography Course and the Alfred TOE course and teaches on many of the other Alfred courses including the Ultrasound, ECMO and HeART courses.

 
Want More??
Check out Dr. Murphy’s talk from smaccGOLD on “ECMO: What could go wrong?”

Also, check out the incredible resources on ECMO on the INTENSIVE blog (the Alfred ICU Education blog)]]>
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EDECMO 29 – ECMO in Hypothermic Cardiac Arrest – with Torvind Naesheim of Norway https://edecmo.org/edecmo-29-subarctic-ecmo-torvinde/ Wed, 13 Jul 2016 08:27:20 +0000 https://edecmo.org/?p=2595 Joe interviews Torvind Naesheim, an intensivist and cardiothoracic anesthesiologist from Norway, on the management of accidental hypothermic arrest using ECMO Joe interviews Torvind Naesheim, an intensivist and cardiothoracic anesthesiologist from Norway, on the management of accidental hypothermic arrest using ECMO  

 

University of North Norway, Tromso

University Hospital of North Norway:

* located at 69 degrees North latitude - likely the northernmost ECMO center in the world.
* The warmest month is July with a mean air temperature of 11.8C and mean sea temperature of 10.8 C.
* The coldest month is January with a mean air temperature of -4.4 C and mean sea temperature of 5.1 C.
* ECMO program since 1988
* Yearly ECMO volume is approx 20 per year - including postcardiotomy support, ECPR, cardiogenic shock and respiratory failure
* ECMO Retrieval Ambulance service: Since 12/2015: 5 ECMO transports
* Cases are reported through the ELSO registry

Accidental Hypothermia - some definitions:
mild : 32-35 C - preserved capability to maintain core temperature through compensating thermoregulatory mechanisms
Moderate: 28-32 - loss of ability to sustain temperature via either voluntary or autonomic means
Severe: 20-28 - high risk of malignant arrhythmias
Profound: <20 Asystole

The Paper: Hilmo, J et al. Prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas - A retrospective study from northern Norway. Resuscitation , Volume 85 , Issue 9 , 1204 - 1211

* "Nobody is dead until warm and dead"
* retrospective study looking at accidental hypothermia victims with cardiac arrest admitted to UNN between 1985-2013
* no survivors prior to 1999
* 1999-2013: 9/24 (37.5%) survival, defined as alive at 1 year - most with a 'favorable' neurologic outcome
* PRIOR studies suggested that asphyxiation, either via snow burial (avalance) or water submersion had a lower chance of survival, but this study suggests that hypothermic arrest during submersion injury may be very different. It is hypothesized that very cold temps create faster cooling rates and aspiration of cold water may induce rapid protective cerebral hypothermia. So drowning victims (asphyxia by submersion in cold water may have a higher survival)
* Hyperkalemia is bad (>8 is bad; >12 is dead)
* Bottom Line: "No patient is dead until they are warm and dead" - current neuroprognostication can't identify OHCA patients who may be salvageable.  So assume they are!

Key ECMO Points:

* Profoundly hypothermic patients cannot generate high flow rates - possibly due to increase blood viscosity.  Consider larger cannulae. Torvinde uses 29F venous and 21F arterial as a starting point.
* Rewarm with a veno-arterial temperature gradient of no more than 10 degrees C. Faster rewarming may result in bubble formation. Torvinde does this via the water bath heater/cooler.
* Therapeutic hypothermia is still in play. Torvinde holds the core temp at 36 for 24-28 hours.
* "You're not dead unless you're warm and dead" - consider transporting potentially salvageable patients with a reliable history.

The Story of Anna Bågenholm was told in this article in the Lancet:



 

 

 ]]>
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EDECMO 28 – The University of Utah EDECMO Experience and the ERECT Collaborative https://edecmo.org/edecmo-28-utah/ Thu, 09 Jun 2016 07:59:51 +0000 https://edecmo.org/?p=2593 Zack talks with the ED ECMO team from the University of Utah about how they established their ECPR program. Zack talks with the ED ECMO team from the University of Utah about how they established their ECPR program. Joe Tonna MD - Emergency Physician with fellowship training in intensive care, Associate Director of ECMO Services

 

Scott Youngquist - Emergency Physician, Prehospital Specialist

 

Steven McKellar - CT Surgeon

 

 

 

 

 

 

]]>
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EDECMO 27 – A Real-World Case of a Crashing Multi-Drug OD Patient Saved with ED ECMO https://edecmo.org/edecmo-27-real-world-case-crashing-multi-drug-od-patient-saved-ed-ecmo/ Thu, 28 Apr 2016 07:39:47 +0000 https://edecmo.org/?p=2255 This is a real-world case of a multi-drug overdosed patient that would have died without ECMO. We talk about ECMO being a bridge to an intervention. Well, sometimes ECMO is a bridge to metabolism of drug/med that they OD'd on. This is a real-world case of a multi-drug overdosed patient that would have died without ECMO. We talk about ECMO being a bridge to an intervention. Well, sometimes ECMO is a bridge to metabolism of drug/med that they OD'd on. Dan McCollum MD

Dan McCollum MD
Assistant Program Residency Director at Georgia Regents University
Augusta, Georgia
Academic Medical center, Level 1 Trauma Center: census >90,000/yr
"If someone is doing an effective therapy out of the back of a truck successfully, and you can’t make it work in your hospital, then you suck and should feel bad."


Case: 38 y/o female multi-drug OD on (possibly):

* Montelukast 10 mg (Singulair) - leukotriene receptor antagonist. mild tox profile (3698 pediatric ingestions from Texas Poison Control: 95% asymptomatic)
* Promethazine 25 mg (Phenergan) - Anticholinergic (56% tachycardia, 42% delirium, 2% mechanical ventilation, 1% hypotension)
* Cyproheptadine 4 mg  - Anticholinergic; mild tox profile (892% of OD in one case series had no or mild symptoms)
* Clonazepam 1 mg (Klonipin) - Common: respiratory depression and hypotension; Rare: heart block/dysrythmia
* Amitriptyline 25 mg - TCA - Hypotension.  QRS widening with R wave in AVR

* Treatment:

* antidote = sodium bicarbonate
* crystalloid for hypotension
* Pressors for refractory hypotension




* Amlodipine 5 mg - Calcium Channel Blocker - Common: Bradycardia, hypotension, heart block; Rare: apnea, pulmonary edema, ARDS, coma, Lactica acidosis, hypoerglycemia, bowel infarction

* Treatment:

* IVF
* High Dose Calcium (inotrope)
* Pressors - Isoproterenol
* Glucagon
* Atropine
* High Dose Insulin - 1-10 unit/kg/hr infusion (consider simultaneous glucose infusion)





 

Timeline before ECMO:

* 02:00-17:00     Estimated time of ingestion:  (2-15 hours PTA).
* 19:00                 Presentation to ED
* 19:30                 BP 55/33; sats 93% on 60% FiO2
* 19:41                  PEA ARREST #1

* Epinephrine, Atropine, Sodium Bicarbonate, Calcium Gluconate, D50
* Narcan > No response


* 19:54                  Bradycardia with pulse
* 20:10                  Bicarbonate gtt
* 20:15                  Epinephrine gtt
* 20:18                  High Dose Insulin bolus, then gtt
* 20:31                  TC pacing
* 20:40                 Norepi gtt, Charcoal
* 20:46                 CXR = pulmonary edema
* 21:07                  Bivent initiation
* 21:14                  Intralipid bolus
* 21:16                  Glucagon
* 21:21                  43/29 with sats 69% and pulse 70
* 21:31                 pRBC transfusion initiated



Total Meds used in resuscitation:

* Calcium Gluconate:                21 Amps
* Sodium Bicarbonate:             19 Ams
* Epinephrine:                           9.5 mg + drips
* Insulin:                                     ~150 units

Complications during hospitalization (but the patient is alive!):

* AF with RVR
* DVT
* ipsilateral limb ischemia > Necrotizing fasciitis > AKA
* Pleural Effusion > chest tube
* Bowel perforation (due to ischemia) > laparotomy
* Trach/PEG
* Abdominal Wall Abscess > I&D

clean 34:22
EDECMO 26 – “ECPR is a Step Too Far” – Ho vs. Bellezzo: a SMACCback Chicago Cage Match https://edecmo.org/edecmo-26-ecpr-is-a-step-too-far-ho-vs-bellezzo-a-smacc-chicago-cage-match/ Wed, 02 Mar 2016 05:50:00 +0000 https://edecmo.org/?p=2483 Are you ready for this rumble in the urban jungle?? Chris Ho vs Joe Bellezzo in the no holds barred debate about whether ECMO CPR is a step too far? The next cage match from SMACC Chicago. Are you ready for this rumble in the urban jungle?? Chris Ho vs Joe Bellezzo in the no holds barred debate about whether ECMO CPR is a step too far? The next cage match from SMACC Chicago. ***republished with permission from the SMACC team from: http://www.smacc.net.au/2016/02/chris-ho-vs-joe-bellezzo-ecpr-is-a-step-too-far/
Are you ready for this rumble in the urban jungle?? Chris Ho vs Joe Bellezzo in the no holds barred debate about whether ECMO CPR is a step too far? The next cage match from SMACC Chicago.

Chris and Joe are the director and vice-director respectively, of Emergency Medicine at Sharp Memorial Hospital in San Diego, California. They are two of the leading experts in ECPR, with Joe being one of the key players behind EDECMO. On a day-to-day basis, they are friends and colleagues, working together in one of the very few centers around the world to deliver ECPR. However in this Cage Match, friends become foe and there are no limitations to how far each will go to prove their side of the debate.

On the AFFIRMATIVE side, Chris Ho delivers a convincing argument for why ECPR IS a step too far. From lack of evidence to the cost of “re-animating the dead” and everything in between, Chris Ho delivers a practical approach to the argument and demonstrates without a doubt why we are not ready for this to be the next step in resuscitation.

On the NEGATIVE side, Joe Bellezzo delivers an outstanding rebuttal to “Dr Ho’s Nutty Brown Bullshit”. In an inspiring argument filled with anecdotes and occasional facts, Joe Bellezzo makes it impossible to think the ECPR shouldn’t be the next step in our ALS algorithm,

Despite strong arguments from either side, as in all debates, there must be a winner. Do you agree with the outcome?

If you want to find out whether Chris and Joe were able to kiss and make up, check out the exclusive ICN interview with the two, where they discuss more on ECPR.
Also check out the 'SMACCback' interview of Ho and Bellezzo by Sophie Connolly and Alice Young of the SMACC Chicago team:

]]> the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 30:00 EDECMO 25.5 – (Part 2) an EDECMO short with Jim Manning – on location with the SAMU pre-hospital ECMO team in France https://edecmo.org/edecmo-25-5/ Mon, 30 Nov 2015 06:55:59 +0000 https://edecmo.org/?p=2367 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." 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." 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

SAMU Ambulance

Lionel Lamhaut and the SAMU ambulance

Manning & SAMU]]>
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EDECMO 25 – ‘Ze ECMO TEAM.’ Manning and Lamhaut: Updates on ECMO, the new 7F REBOA Catheter, and Pre-hospital ECMO in France https://edecmo.org/edecmo-25-ze-ecmo-team-manning-and-lamhaut-updates-on-ecmo-the-new-7f-reboa-catheter-and-pre-hospital-ecmo-in-france/ Thu, 19 Nov 2015 08:53:27 +0000 https://edecmo.org/?p=2345 In this episode, Zack interviews Jim Manning MD (University of North Carolina) and Dr. Lionel Lamhaut from the famed French SAMU (Service d'Aide Médicale Urgente). REBOA. SAAP. Pre-Hospital ECMO. Its all here. In this episode, Zack interviews Jim Manning MD (University of North Carolina) and Dr. Lionel Lamhaut from the famed French SAMU (Service d'Aide Médicale Urgente). REBOA. SAAP. Pre-Hospital ECMO. Its all here. 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:

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:

* Medical Cardiac Arrest
* Age < 75
* No Flow < 5 min (bystander CPR must be started within 5 min)
* Hypothermia is always considered
* Intoxications (of any kind) are always considered
* 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...

 

 

 

 ]]>
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The Rat Pack: Another Year of EDECMO (2014/2015) – Video https://edecmo.org/the-rat-pack-another-year-of-edecmo-20142015-video/ Sun, 04 Oct 2015 03:25:17 +0000 https://edecmo.org/?p=2298 The Rat Pack: The Last Year of EDECMO! The Rat Pack: The Last Year of EDECMO! the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 1:59 EDECMO 24 – Weaning VA-ECMO, with Deirdre Murphy https://edecmo.org/edecmo-24-weaning-va-ecmo-with-deirdre-murphy/ Thu, 10 Sep 2015 04:01:52 +0000 https://edecmo.org/?p=2245 In this episode, Zack and Joe talk with Deirdre Murphy, the Deputy Director of the ICU, director of the cardiothoracic ICU at the Alfred Hospital in Melbourne, Australia. The Alfred has put itself on the map in so many ways over the past decade. Home to Stephen Bernard (of the original Hypothermia after ROSC without RONF fame), Chris Nickson (@precordialthump, @I_C_N, @intensiveblog, #SMACC, lifeinthefastlane.com), and good friends Jason McClue, Steve McGloughlin, Josh Ihle, Paul Nixon, and Deirdre Murphy, The Alfred is becoming a mecca for advanced resuscitation and ECMO/ECPR. In this episode we sat down with Dr. Murphy to discuss the nuances of weaning a patient from ECMO. As ED Docs, Zack and I find ourselves at the heroic end of the resuscitation spectrum when the dying patient goes on pump...but what happens at the other end? What happens in the hours, days, and weeks that follow? Listen to this episode to find out... In this episode, Zack and Joe talk with Deirdre Murphy, the Deputy Director of the ICU, director of the cardiothoracic ICU at the Alfred Hospital in Melbourne, Australia. The Alfred has put itself on the map in so many ways over the past decade.
As ED Docs, Zack and I find ourselves at the heroic end of the resuscitation spectrum when the dying patient goes on pump...but what happens at the other end? What happens in the hours, days, and weeks that follow?  Listen to this episode to find out...

 

Deirdre Murphy MB (Hons), MRCPI, FCARCSI, FCICM, DDU (Crit Care), PGDipEcho

Deirdre Murphy MB (Hons), MRCPI, FCARCSI, FCICM, DDU (Crit Care), PGDipEcho
Deirdre is Deputy Director ICU, Director of the Cardiothoracic ICU at The Alfred Hospital with particular interests in echocardiography and cardiac intensive care, especially mechanical circulatory supports including Ventricular Assist Devices and ECMO. Deirdre originally trained in Ireland with postgraduate training in general medicine and anaesthesia prior to undertaking intensive care training in Australia in 1999. She has been an Intensivist at The Alfred since 2003. Deirdre has been using echo in clinical practice since 2002 and heads the ICU echocardiography programme at the Alfred. She is convenor of the Alfred Critical Care Echocardiography Course and the Alfred TOE course and teaches on many of the other Alfred courses including the Ultrasound, ECMO and HeART courses.
A paper just published in Intensive Care Medicine followed this algorithm:
(Intensive Care Med (2015) 41:902-905)
How to wean a patient from veno-arterial extracorporeal membrane oxygenation

Some Notes
Signs of improvement

* Pulsatility indicates the patient is getting better
* ETCO2 starts to rise
* Weaning Vasopressors

 
Want More??
Check out Dr. Murphy's talk from smaccGOLD on "ECMO: What could go wrong?"

Also, check out the incredible resources on ECMO on the INTENSIVE blog (the Alfred ICU Education blog)
Update:
Can we use ETCO2 to assess weaning?



 ]]>
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EDECMO 23 – ORNATO LIVES! – How ECMO Saved a Pillar of Resuscitation https://edecmo.org/edecmo-23-ornato-lives-how-ecmo-saved-a-pillar-of-resuscitation/ Tue, 14 Jul 2015 17:00:44 +0000 https://edecmo.org/?p=2150 Joe Ornato, a pillar in the world of resuscitation, suffered a massive PE and arrested upon arrival to the Virginia Commonwealth University Emergency Department in April 2015. How it all unfolded is amazing. Listen to this episode to hear the details... Joe Ornato, a pillar in the world of resuscitation, suffered a massive PE and arrested upon arrival to the Virginia Commonwealth University Emergency Department in April 2015. How it all unfolded is amazing. Listen to this episode to hear the details... Dept of Emergency Medicine. Joseph Ornato MD

"They RSI'd me...they cannulated me...
Here I am today, two months later..."
Joe Ornato, a pillar in the world of resuscitation, suffered a massive PE and arrested upon arrival to the Virginia Commonwealth University Emergency Department in April 2015.  First: hats off!!! to the Emergency Department, the resuscitation team, the CT surgeons and entire staff at VCU. How it all unfolded is amazing! You MUST listen to this episode to hear the details...

Joseph P. Ornato, MD, FACP, FACC, FACEP

Dr. Joseph P. Ornato is professor and chairman of the Department of Emergency Medicine at Virginia Commonwealth University Medical Center in Richmond, Virginia. He is also medical director of the Richmond Ambulance Authority, the Prehospital Paramedic System serving Richmond, Va. Dr. Ornato is triple board certified (internal medicine, cardiology, emergency medicine) and is an active researcher in the field of cardiopulmonary resuscitation. Dr. Ornato is an editor of the journal Resuscitation. He is past Chairman of the American Heart Association's (AHA) National Emergency Cardiovascular Care Committee and its Advanced Cardiac Life Support Subcommittee. He chaired the National Steering Committee on the NIH Public Access Defibrillation Trial. He is currently consultant and cardiac co-chairman of the NIH Resuscitation Outcomes Consortium (ROC) and serves as principal investigator for VCU on the NIH-sponsored Neurological Emergency Treatment Trials (NETT) Network. Dr. Ornato is a member of the Institute of Medicine.

Dr. Ornato and the prehospital trauma team



 

"We lose the equivalent of one medium sized American city to the problem of sudden, unexpected cardiac arrest each year. The best weapon we have against this killer is early defibrillation. We need to move quickly to saturate the chain of survival, particularly the early defibrillation  component, in every community."
-Joe Ornato, MD, FACC, FACEP]]>
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EDECMO 22 – Managing the Crashing Tox Patient with ECMO – with Leon Gussow & Steve Aks from The Poison Review https://edecmo.org/edecmo-22-managing-the-crashing-tox-patient-with-ecmo-with-leon-gussow-steve-aks-from-the-poison-review/ Mon, 15 Jun 2015 12:00:26 +0000 https://edecmo.org/?p=2027 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. 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. ...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.

Check out THE POISON REVIEW and Subscribe to them in iTunes
Leon 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"

Steve Aks DO, FACMT, FACOEP, FACEP
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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REANIMATE SAN DIEGO 2016: February 25-26, 2016 https://edecmo.org/reanimate-san-diego-2016-february-25-26-2016/ Mon, 25 May 2015 06:54:35 +0000 https://edecmo.org/?p=2051 REANIMATE is a 2-day conference that will teach you everything about Resuscitative ECMO and Extracorporeal Cardiopulmonary Resuscitation (ECPR). The conference will be hosted by Zack Shinar, Scott Weingart, and Joe Bellezzo REANIMATE is a 2-day conference that will teach you everything about Resuscitative ECMO and Extracorporeal Cardiopulmonary Resuscitation (ECPR). The conference will be hosted by Zack Shinar, Scott Weingart, and Joe Bellezzo REANIMATE SAN DIEGO 2016:       February 25-26, 2016 in beautiful San Diego, California, USA.
ABOUT THE CONFERENCE:
REANIMATE is a 2-day conference that will teach you everything about Resuscitative ECMO and Extracorporeal Cardiopulmonary Resuscitation (ECPR). Multidisciplinary teamwork and human factors will be stressed throughout. Sessions will have a heavy emphasis on acquiring hands-on skills associated with initiation of ECMO including:


Cannulation Technique
ECMO Physiology
Pump Troubleshooting
Cardiac Arrest & Peri-ECMO Resuscitation

ABOUT THE FACULTY:
The REANIMATE faculty will include some of the brightest minds in all of Resuscitation Medicine. The EDECMO team will be joined by some of the best teachers in the ECMO world. Check out the Faculty Page to see more about our incredible professors. Also check out the Schedule of Events.

ABOUT THE LOCATION
REANIMATE will be held at the UCSD Simulation Center in San Diego, California. The Sim Center offers gorgeous classrooms and state of the art simulation capabilities. The surrounding area is amazing. Torrey Pines golf course and recreation center are a short walk away. Beaches with surfing, volleyball and swimming are also within 3 miles of the Sim Center. The conference will make use of these areas with a beach trip and hiking of Torrey Pines on the agenda.

 

February is one of the most beautiful times of the year to visit San Diego.  Bring the family and make it a vacation!

REGISTER TODAY! space is limited]]>
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EDECMO 21- The Vienna Project: A Randomized-Controlled Trial of ECPR for Out-Of-Hospital Cardiac Arrest https://edecmo.org/edecmo-21-the-vienna-project-a-randomized-controlled-trial-of-ecpr-for-out-of-hospital-cardiac-arrest/ Thu, 21 May 2015 00:02:23 +0000 https://edecmo.org/?p=1996 In this episode Zack talks with Dr. Schoeber about their newest endeavor, the holy grail: a randomized-controlled trial comparing "Load & Go" (transporting OHCA patients to the ED immediately for consideration of ECMO) vs. "standard care" (staying on scene until the patient achieves either ROSC or is pronounced dead). Zack and Andreas talk about the impact this could have on the future of ECPR for OHCA. In this episode Zack talks with Dr. Schoeber about their newest endeavor, the holy grail: a randomized-controlled trial comparing "Load & Go" (transporting OHCA patients to the ED immediately for consideration of ECMO) vs. Andreas Schober is an Emergency Medicine physician and resuscitationist from the Medical University of Vienna. Dr. Schober is a world-expert in resuscitation, ECPR, and cardiac arrest. We met Schober in Chicago at the 2014 American Heart Association (AHA) Resuscitation Symposium (ReSS) where he presented their experience with a "Load & Go" model for out-of-hospital cardiac arrest (OHCA): 



In this episode Zack talks with Dr. Schoeber about their newest endeavor, the holy grail: a randomized-controlled trial comparing "Load & Go" (transporting OHCA patients to the ED immediately for consideration of ECMO) vs. "standard care" (staying on scene until the patient achieves either ROSC or is pronounced dead).  Zack and Andreas talk about the impact this could have on the future of ECPR for OHCA.
Announcements:
SMACC Chicago 2015: There is still time to register for SMACC - the biggest and baddest ED Critical Care conference in the World. Just check out the lineup of speakers! You won't want to miss this.

Reanimate San Diego 2016:  The EDECMO team has put together a crew of world-class educators to teach you how to set up an ED ECMO program, teach you how to initiate ECPR in arresting patients, and teach you how to manage patients after they are on "on-pump". Please join us in "America's Finest City," San Diego, California, for 2-day immersion in ECPR. We are limiting the conference size to maximize your learning experience, so registration will sell out quickly:
Register for Reanimate San Diego 2016
 

**Special thanks to Camille Hudon for providing the "International Introduction", in French, to this episode!!!  That was recorded in a small restaurant in Montreal during Bring Me Back To Life 2014

 

 ]]>
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EDECMO 20 – The Golden Hour & the Rule of 3’s: Optimizing the Critical First Hour on Heart-Lung Bypass https://edecmo.org/edecmo-20-the-golden-hour-the-rule-of-3s-optimizing-the-critical-first-hour-on-heart-lung-bypass/ Sat, 11 Apr 2015 21:15:57 +0000 https://edecmo.org/?p=1956 In this episode, Joe talks about that first critical hour on Heart-Lung Bypass. What are the most common and critical clinical scenarios that the ECMO operator faces in that first hour on pump? Listen to this episode to find out. In this episode, Joe talks about that first critical hour on Heart-Lung Bypass. What are the most common and critical clinical scenarios that the ECMO operator faces in that first hour on pump? Listen to this episode to find out. Upcoming Conferences:

* SMACC 2015: June 23-26, 2015. The biggest and baddest critical care conference of the year is in Chicago this year.
* Essentials of Emergency Medicine 2015. October 13-15, 2015. The Big Show. In Vegas. At the Cosmopolitan.
* Reanimate San Diego. February 25-26, 2016. The essentials of ECMO in 2 glorious days. Here is a sneak peak at the Reanimate 2016 Promo Video.

Flipped Classroom SMACC ECMO Workshop 2015
For those taking the upcoming ECMO courses with us, download both of these 2 attachments. The first is a diagram of a traditional ECMO circuit - its nice to print this out and follow along. Not every circuit is the same and we have ours custom built by Maquet.  The second is a self-study course.  While it isn't necessary to review these before our workshop, it will really put you ahead of the game and we focus more on procedures.


Figure 1. The Custom Maquet ECMO Circuit

Study Guide

Review of the 3 stages of ECPR

* STAGE 1: Placement of any commercially available vascular catheter in the femoral vein and femoral artery
* STAGE 2: Replacement of each catheter with ECMO cannulae. Checkout EDECMO 5: Cognitive Task Management for ED ECMO Stages 1 and 2. Also, we learned several cannulation pearls from Stephen Bernard in EDECMO 14 Part 1 and Part 2
* STAGE 3: Initiation of Total Heart Lung Bypass

ECMO Circuit Setup:

* Plug in the machine and power-on the heater-cooler and the Rotaflow console.
* Unpackage the circuit and hold it up to orient yourself.
*

Mounting the Rotaflow Pump to the Pump Drive

Attach the Oxygenator to the bracket and the pump to the pump-drive; hang the distal ends of the circuit (the tubes that will connect to the patient) from the IV pole.
* Apply ultrasonic contact cream to the flow probe contact site
* Remove and DISCARD the yellow de-airing exit port cap on the top of the oxygenator.
* Connect the water lines from the heater-cooler to the Quadrox Oxygenator & open the stopcocks.
* "Run the circuit", making sure that the recirculation bridge is OPEN, arterial and venous tubing is CLAMPED, rapid-prime tubes are CLAMPED, both of the blood sampling "pig tail" stopcocks are CLOSED.
* PRIME the circuit:  Priming the Circuit: Filling the ECMO circuit (tubing, pump, oxygenator) with crystalloid priming solution (ie Isolyte), adding 2,500 units of heparin to each 1-liter bag of priming solution.  We discuss the finer details of this with Greg Griffin, the Chief Perfusionist at the University of North Carolina, Chapel Hill in EDECMO 8.

* squeeze all air out of prime bag INTO the circuit and then hang those bags from the IV pole.
* Open the ratchet clamps: the circuit will fill (prime) by gravity.


* Connect the Oxygen supply line (from Oxygen tank) to the Oxygen inlet port on the oxygenator<...]]>
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ECMO Simulation Model Built by Zack!! https://edecmo.org/ecmo-simulation-model-built-by-zack/ Fri, 20 Mar 2015 18:28:11 +0000 https://edecmo.org/?p=1912 Using parts purchased at Home Depot, Zack took apart a Tall Paul Anatomy Mannequin and built the whole thing from scratch. This is how it went down! Using parts purchased at Home Depot, Zack took apart a Tall Paul Anatomy Mannequin and built the whole thing from scratch. This is how it went down! Castlefest 2015?               CHECK

Make travel arrangements for SMACC 2015 in Chicago?                                    CHECK

Build a complete ECMO simulator using a Tall Paul anatomy mannequin, some PVC tubing, off-the-shelf items from Home Depot, and a cordless drill?

Well...

Using parts purchased at Home Depot, Zack took apart a Tall Paul Anatomy Mannequin and built the whole thing from scratch.  This is how it went down!



And check out the video at 2:22: Zack powers the Maquet Rotaflow pump using an electric hand drill with magnets attached to a plastic disc.

 ]]>
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EDECMO 19 – ECPR for Out-of-Hospital Cardiac Arrest Japanese-Style! https://edecmo.org/edecmo-19-ecpr-for-out-of-hospital-cardiac-arrest-japanese-style/ Thu, 19 Feb 2015 23:35:22 +0000 https://edecmo.org/?p=1873 Tetsuya Sakamoto is the principal investigator of a multi-center prospective observational study that was just recently published in the journal Resuscitation: Resuscitation. 2014 Jun;85(6):762-8. Zack and Joe met with Dr. Sakamoto during the 2014 AHA RESS conferences and talked all things ECPR. After that, Shinar sat down with Dr. Sakamoto to get his take on how the Japanese EMS system is setup and how they are able to implement ECPR into their resuscitation protocols. Tetsuya Sakamoto is the principal investigator of a multi-center prospective observational study that was just recently published in the journal Resuscitation: Resuscitation. 2014 Jun;85(6):762-8. Zack and Joe met with Dr. Tetsuya Sakamoto is the principal investigator of a multi-center prospective observational study comparing ECPR vs. traditional resuscitation for out of hospital cardiac arrest. His study was just recently published in the journal Resuscitation: Resuscitation. 2014 Jun;85(6):762-8. Zack and Joe met with Dr. Sakamoto during the 2014 AHA RESS conferences and talked all things ECPR.  After that, Shinar sat down with Dr. Sakamoto to get his take on how the Japanese EMS system is setup and how they are able to implement ECPR into their resuscitation protocols.

 

The Japanese Emergency Care System

* Ambulance Crew = 1 EMT paramedic + 2 EMT's

* EMT paramedic

* Epi
* Intubate


* 2 Basic-trained EMT's


* Hospital Systems:

* General Hospital
* Tertiary Hospital Receiving Centers (271 Centers)

* Trauma
* Resuscitation
* Critical Care




* Emergency Department at Japanese Tertiary Care Center

* Emergency ICU
* Trauma resuscitation, PCI, etc.
*


* Pre-hospital protocols for Termination of Resuscitation protocols in Japan

* In Japan, prehospitals providers are not empowered to pronounce
* Average time on Scene = 10-20 min (scoop and run!)
* They transport everyone!



Percutaneous Cardiopulmonary Support (ECMO) and the Save-J team

*  20 years ago: initial case reports in Japan suggested a benefit for ECPR for in-hospital cardiac arrest failing ACLS.
* In 2009 a landmark paper by Ken Nagao showed benefit of ECPR + therapeutic hypothermia in a single hospital for out-of-hospital arrest.: Early Induction of Hypothermia During Cardiac Arrest Improves Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Who Undergo Emergency Cardiopulmonary Bypass and Percutaneous Coronary Intervention
* So, a multi-center study was needed. 5 years ago several investigators in Japan created a multi-center study: The SAVE-J study:

* Save J was a multi-center RCT for out-of-hospital cardiac arrest by comparing resuscitation success rates for hospitals who provided ECPR with those that did not.
* reviewed by Joe and Zack for EVID-ECMO.
* Save J inclusion criteria:

* Transport to hospital within 45 min of arrest
* Age < 75
* VF/VT as initial rhythm
* No ROSC before intiation of ECPR


* Compared extremely ill patients with very little chance of survival
* Results:

* ECPR: 10-20% survival
* No-ECPR: 2% survival





Final Thoughts

* ECPR has huge promise for saving the lives of patients who would otherwise not survive with standard ACLS. But the cost is not trivial. So,

* we need to drill down into the inclusion criterion to ensure we are using this therapy on patients who will gain the most benefit.
* ECPR requires a team-approach, much like a trauma team activation.  The successful ECPR team still demands good-quality chest compressions, appropriate use of ACLS protocols, etc.
* Training is important because cannulation during arrest is tough.


]]>
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EDECMO 18 – Remote Ischemic Conditioning – with Graham Nichol https://edecmo.org/edecmo-xx-limiting-post-arrest-ischemia-reperfusion-injury-graham-nichol/ Mon, 05 Jan 2015 12:00:51 +0000 https://edecmo.org/?p=1412 In this episode Zack & Joe talk with Graham Nichol about how to use remote ischemic conditioning to reduce ischemia-reperfusion injury after cardiac arrest. In this episode Zack & Joe talk with Graham Nichol about how to use remote ischemic conditioning to reduce ischemia-reperfusion injury after cardiac arrest. In this episode Zack and Joe talk with a true pioneer in resuscitation and the science of cardiac arrest management. Graham Nichol, from the University of Washington,  joined us at Sharp Memorial Hospital for an amazing discussion about "Remote Ischemic Conditioning" and its role in prevention of ischemia-reperfusion injury resulting from cardiac arrest.  Is this VooDoo or a real phenomenon? Listen to this episode to find out...
Some Definitions:

* "Ischemia-Reperfusion" injury:  prolonged ischemia to the brain and heart often occur after circulatory arrest. Immediate CPR minimizes this phenomenon but many of our patients who arrest in the pre-hospital setting don't receive immediate bystander CPR, resulting in prolonged ischemia. CPR reintroduces blood flow and oxygen to the previously ischemic tissues.  This hyperoxic 'reperfusion' is known to be a main contributor to infarct size in  both the heart and brain causing poor neurologic outcomes after arrest. Minimizing this reperfusion injury is major focus of resuscitative science right now.
* "Ischemic Conditioning": purposeful application of ischemia and reperfusion, off and on, to the tissues.

* "Pre-conditioning" = applying this therapy BEFORE circulatory arrest
* "Peri-conditioning" = applying this therapy either DURING circulatory arrest
* "Post-conditioning" = applying this therapy AFTER circulatory arrest


* "Targeted" vs. "Remote" Ischemic Conditioning:
   "Targeted" ischemic conditioning: application of conditioning directly to the  specific target organ (ie the heart or the brain). This can be done in one of two ways:

* systemic  ischemic conditioning.

* In a pig model of cardiac arrest, Demetris Yannapoulos and Keith Lurie applied brief periods of ischemic post-conditioning via "Stutter CPR" (3-4 cycles of 20 seconds of CPR with 20 second pauses) after prolonged "no flow" arrest - upwards of 20 minutes without CPR - and found normal LV function and elimination of ischemic insult to the brain using this technique.   They discussed this controversial topic with Weingart on the emcrit podcast Episode 69.


* Local conditioning: applying ischemic conditioning directly to the target organ

* Many studies have shown effectiveness of local ischemic conditioning during PCI for acute MI.  After restoration of vessel patency, reperfusion was interrupted by cycles of 1 min of coronary balloon reocclusion. Here is a good summary:

* Staat Post-Conditioning the Human Heart 2005







 "Remote" ischemic conditioning: application of ischemic conditioning to a REMOTE area of the body (ie the limb) to reduce the degree of injury to the heart and brain that results from cardiac arrest (ischemia) followed by reperfusion (chest compressions, ROSC, or ECMO) by applying the 'remote' ischemia-reperfusion by using a blood pressure cuff on a limb.

How it Works:
*courtesy of the Lancet Vol 374; Oct 2009
Several theories exist to explain the benefit of ischemic conditioning. I'll break it down in two ways:
1.)  Simple explanation: "good humors" are released from the ischemic limb and protect against cell death/apoptosis in the heart and brain.
2.) Complex hypothesis:
1.) RIC induces a cascade of intracellular kinases and modifies mitochondrial function within the cell by opening ATP-sensitive potassium channels and closing the mitochondrial permeability trans...]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 20:49
EM:RAP Mini – Zack & Joe recap AHA 2014: ‘bleeding edge’ interventions in the ED https://edecmo.org/emrap-mini-zack-joe-talk-recap-aha-2014-bleeding-edge-interventions-ed/ Mon, 22 Dec 2014 00:02:46 +0000 https://edecmo.org/?p=1769 In this short segment that was generously produced and offered by the EM:RAP team, Zack and Joe recap some the the big topics from the American Heart Association 2014 conference in Chicago. In this short segment that was generously produced and offered by the EM:RAP team, Zack and Joe recap some the the big topics from the American Heart Association 2014 conference in Chicago. EM:RAP team, Zack and Joe recap some the the big topics from the American Heart Association 2014 conference in Chicago.  There were a few topics that hit home for the Resuscitationist:

1. REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) - is this ready for prime time yet? well, Zack recently placed a REBOA catheter in a patient with non-compressible blunt trauma to the pelvis at Sharp Memorial Hospital. Its a hot topic right now and was also reviewed in the December 2014 issue of EM:RAP with Stuart Swadron and Kenji Inaba.

2. TTM: Targeted Temperature Management - 33 degrees or 36 degrees after ROSC without RONF? Controversy brews over the ideal temperature for these patients.

3. ECMO at the cutting edge:

* Paris: pre-hospital ECMO?
* Vienna: Load & Go trumps Stay & Play in France

4. TTM for trauma? Sam Tisherman and Pat Kochanek from the Unversity of Pittsburgh  have partnered with Tom Scalea's team at Maryland Shock Trauma and have established a new trial: EPR-CAT (Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma).  This study takes patients with hemorrhagic cardiac arrest, replaces the blood volume with 10 degrees cold saline, takes them to the OR to fix the holes, then puts them on ECMO to resuscitate them.

5. Mechanical chest compression devices: we acknowledge that the trials have shown neither statistical benefit or harm, but for those of us doing extreme resuscitation of the medical arrest, their are intangible benefits that must be considered.

 


Bibliography:
REBOA -  Brenner M et al. J Trauma Acute Care Surg. 2013 Sep;75(3):506

TTM- Nielsen N et al. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest.  N Engl J Med 2013; 369:2197-2206

Mech CC Device - Rubertsson S.  Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest.  JAMA. 2014;311(1):53-61

 

*Thanks to Mel and the entire EM:RAP team for producing this EM:RAP mini and allowing us to repost it. If you aren't already an EM:RAP subscriber, we can't emphasize enough the value of this fantastic educational experience. Please consider subscribing to EM:RAP. (No disclosures; Mel doesn't pay us to say that! its just a damn-good show!)]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 11:07
EDECMO 17 – The Reanimateur: Lionel Lamhaut on Pre-Hospital ECPR https://edecmo.org/edecmo-17-reanimateur-lionel-lamhaut-pre-hospital-ecpr/ Wed, 10 Dec 2014 21:57:47 +0000 https://edecmo.org/?p=1713 In this episode Zack talks with Lionel Lamhaut, a physician who is heading up their pre-hospital ECMO program. Yes, they are really doing ECMO in the field. In this episode Zack talks with Lionel Lamhaut, a physician who is heading up their pre-hospital ECMO program. Yes, they are really doing ECMO in the field. 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:

* 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.
* 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.
* 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.]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 15:06
EDECMO 16: The End-of-Life Matrix & The Ethics of Advanced Resuscitation with Dr. Cyrus P. Olsen III, D.Phil. https://edecmo.org/ethics-advanced-resuscitation-dr-cy-olson-professor-ethics-philosophy/ Thu, 20 Nov 2014 11:00:32 +0000 https://edecmo.org/?p=1527 Zack & Joe talk with Dr. Cyrus Olsen about the challenges of deciding who does, and who doesn't, get advanced resusctition. Zack & Joe talk with Dr. Cyrus Olsen about the challenges of deciding who does, and who doesn't, get advanced resusctition.
 
"in regards to ECMO : There's now a space, a hopeful space, to allow patients & family the time to make better decisions." - Cy Olsen PhD

— ED ECMO Project (@edecmo) November 22, 2014

WARNING: This is going to get waaaaay touchy-feely and waaaaay outside of Joe's comfort zone (Zack, on the other hand, is feeling right at home here). With that in mind...

"How young is too young..." to withhold resuscitation?
The Dilemmas:

* How old is too old...or better yet...how young is too young?  aside from routine resuscitation: drugs, chest compressions, shocks, is there an age that is too old for ECMO? We currently use a soft cutoff of 75 yoa. Lets take all of the variables out of the equation and just assume a person has ZERO medical problems and is on ZERO medications. They ambulate on their own, live independently, and they believe they have a good quality of life.  In this scenario, is there any age that is too old for ECMO? This should be our starting point and then move down (in age) from there.  The 95 year old is easy.  The 40 year old is easy. All the rest are tough and that's where we will get criticism for "doing too much."
* Concrete resuscitation cutoff vs. a graded response?  Whatever we decide is the cutoff (age, quality of life, comorbidities), should we use the exact same set of criteria for even initiating CPR as we do for ECMO? Should they be the same? In other words, should we have the same set of criteria for both or should there be a graded response to the dying patient (over 75 I do CPR and intubate but don't do ECMO but under 75 I go full-court-press and possible ECMO)?
* Only Reverse the Reversible. Somehow we need to identify inevitable death and allow that to happen. Greg Henry always says, "Despite all the advances of modern medicine, the death remains the same: one per person."  But when we can't be sure that death is inevitable, does everyone deserve a shot?  In other words, should we be making that decision on the front end (ED) when little information is known to us, or should that be sorted out on the back end...in the ICU?  Is there a way to tell a resuscitationist that its ok to err on the side of over-resuscitation, so long as your intent to is to reverse the reversable? Peter Safar's quote, "Death is not the enemy, but occasionally need help with timing." exemplifies this.
* Define "Quality of Life". How do we determine "Quality of Life"? Who decides this in the heat of the moment? The doctor or the family?
* What is the real goal of resuscitation? Should we only resuscitate people who were previously healthy and have a chance of 100% recovery? It seems we've come to a place where the knee-jerk reaction by ED doctors is to do full CPR on everyone and then see what happens.  So how do we determine when and where to stop?
* MD paternalism vs. patient automony = "The Tyranny of Choice."

 
The Episode Play-by-Play:
Dr. Olsen talks about the first concept: The "3 Senses of Dignity" from Daniel Sulmasy MD, PhD, a spokesman for the President's Council on Biotheics


Intrinsic Dignity = your value for just being human
Attributed Dignity = your "market value" to society
Inflorescent Dignity = your "flourishing"; or your quality of life

Utstein Variables for CPR
 The Life Matrix and the Functional Threshold:
clean 22:59
EDECMO 15: The CHEER Trial & Part 2 of our Interview with Dr. Stephen Bernard https://edecmo.org/edecmo-15-cheer-trial-part-2-interview-dr-stephen-bernard/ Wed, 15 Oct 2014 03:50:16 +0000 https://edecmo.org/?p=1540 In this episode Zack and Joe discuss the CHEER Trial (mechanical CPR, Hypothermia, ECMO, and Early Revascularization) and follow up with Dr. Stephen Bernard with a few more questions about ECMO at the Alfred. In this episode Zack and Joe discuss the CHEER Trial (mechanical CPR, Hypothermia, ECMO, and Early Revascularization) and follow up with Dr. Stephen Bernard with a few more questions about ECMO at the Alfred. interview With Dr. Stephen Bernard from the Alfred Hospital in Melbourne, Australia, the CHEER Trial was published.

Background:   Recently, we reviewed two big papers in the ECPR (Extracorporeal Cardiopulmonary Resuscitation) World: 1.) The Chen Trial (Lancet 2008): a large prospective observational study of in-house arreest (IHCA), out of Taiwan, that showed 32.6% (ECPR) benefit vs. 17% (non-ECPR); and 2.) The Save-J Trial (Resuscitation 2014): a large prospective observational study of Out-of-Hospital cardiac arrest (OHCA) that showed a 11.2% (ECPR) benefit vs. 2.6% (non-ECPR). Indeed these numbers are impressive! We all know that we need a randomized, controlled trial (RCT) but until then the guys at the Alfred Hospital in Melbourne, Australia decided to up the ante and published the initial findings of this pilot study. That study was called CHEER.  This amounts to a hyper-aggressive, bundled protocol that begins on the street (EMS) and ends in the cath lab, whereafter world-class critical care has resulted in some remarkable initial numbers.

 
CHEER (mechanical CPR, Hypothermia, ECMO, & Early Revascularization)
This is a single-center, prospective, pilot study that was done over 32 months.  The primary outcome measure was short and long-term outcomes at CPC 1 or 2 (excellent neurologic outcome). The guys down-under generated inclusion criteria to capture the most salvageable patients who suffered out-of-hospital cardiac arrest (OHCA), combined those with in-hospital cardiac arrest (IHCA) patients and applied the CHEER algorithm:

* CPR (using the Zoll Autopulse)
* Hypothermia (initiated intra-arrest with iced saline)
* ECMO (cannulation in the ED by intensivists)
* Early Revascularization (aka a trip to the cath lab)

Zoll Autopulse (TM)

And all this was begun in the prehospital setting. Since the EMS system in their neighborhood is a single-provider system, they were able to get support from Zoll Pharmaceuticals to supply all of their rigs with their mechanical chest compression device - the Zoll Autopulse. Patients who met inclusion criteria were met by EMS, put on the Autopulse, and transported to the Alfred. EMS also began intra-arrest cooling by rapid infusion of iced saline at 30cc/kg. On arrival to their Emergency Department, intensivists met the patient and began the cannulation process. Once on ECMO the patients were immediately brought to the cath lab for revascularization. IHCA patients received the identical protocol, obviously minus the limo ride to the hospital.

In 2014 this amounts to a super-aggressive bundle therapy that just makes us salivate over here in the US.  Initiating intra-arrest cooling and mechanical chest compressions in the pre-hospital setting is formidable goal for us.

Their results: 26 patients were entered into the protocol (11 with OHCA, 15 with IHCA). The median age was 52 years.]]> the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 31:42 EDECMO Episode #14: ECPR with Stephen Bernard 1/2 https://edecmo.org/edecmo-episode-14-ecpr-stephen-bernard/ Tue, 30 Sep 2014 06:52:41 +0000 https://edecmo.org/?p=1475 In today's episode, Joe and Zack interview Dr. Stephen Bernard about Extracorporeal Cardiopulmonary Resuscitation (ECPR) and how they do it the Alfred in Melbourne, Australia. In today's episode, Joe and Zack interview Dr. Stephen Bernard about Extracorporeal Cardiopulmonary Resuscitation (ECPR) and how they do it the Alfred in Melbourne, Australia. 2002 NEJM 'Treatment of Comatose Survivors of Out-of-Hospital Cardia Arrest with Induced Hypothermia), Dr. Bernard is now at the forefront of ECPR, reshaping pre-hospital dogma and intra-arrest management, including the use of ECMO during cardiac arrest.








Stephen Bernard MB BS, MD, FACEM, FCICM

Professor Stephen Bernard MB BS, MD, FACEM, FCICM


Senior Intensive Care Specialist
The Alfred Hospital
Melbourne, Australia

Adjunct Professor, Department of Epidemiology and Preventive Medicine, Monash University
Medical Advisor, Ambulance Victoria
Member, Medical Advisory Committee, Ambulance Victoria
Member, Clinical Practice Guideline Review Committee, Ambulance Victoria
Member, Clinical Incident Review Committee, Ambulance Victoria
Co-Chair, Steering Committee, Victorian Ambulance Cardiac Arrest Register, Ambulance Victoria
Member, Clinical Committee, Council of Australasian Ambulance Authorities
Medical Officer, Australian Formula 1 Grand Prix
Medical Officer, Australian Motorcycle Grand Prix
Member, National Medical Advisory Committee, Confederation of Australian Motor Sport
Supervisor of PhD students x2
Director of Intensive Care, Knox Private Hospital
Chair, Medical Advisory Committee, Knox Private Hospital
Member, Patient Care Review Committee, Knox Private Hospital





 Today's Episode:

Development of the ECPR protocol at the Alfred in Australia

Reconstruction of the "Chain of Survival"
TOR (termination of resuscitation)


The Alfred ECMO CPR Guideline 2014 version 13: This is the PDF version of their latest ECPR protocol.
The CHEER (CPR, Hypothermia, ECMO and Early Reperfusion)

Check out a GREAT lecture on CHEER by Dr. Bernard that was presented on the Intensive Care Network run by Oli Flower and Matt MacPartlin
Registry: clinicaltrials.gov registry
Updated CHEER results:  You gotta listen to the podcast! This stuff is In Press and soon to be published



 



More!
Quick tips from The Alfred ICU ECMO Course | INTENSIVE http://t.co/F4VvIH23We #FOAMed #FOAMcc

— Chris Nickson (@precordialthump) October 11, 2014


* Weingart's interview with Steve on Post-Arrest care at the Emcrit.org site
* The Alfred ICU education website, INTENSIVE, run by Chris Nickson and Steve McGloughlin:







]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 33:57
Evid-ECMO 2: Veno-Venous ECMO in ARDS – The CESAR Trial & ANZ-ECMO https://edecmo.org/evid-ecmo-2-veno-venous-ecmo-ards-cesar-trial-anzic/ Fri, 26 Sep 2014 07:50:29 +0000 https://edecmo.org/?p=1434 Critical Review of 2 of the big papers on VV-ECMO for ARDS. Critical Review of 2 of the big papers on VV-ECMO for ARDS. Dr. David Willms, who is the Director of Critical Care Medicine at Sharp Memorial Hospital. Dr. Willms has over 25 years of experience with VA and VV ECMO and is an amazing resource for us at our hospital. Dr. Willms has been a key player in the development of our highly successful ECMO program at Sharp. Zack and Dave discuss two of the "big" articles in VV-ECMO for ARDS:

 
Article 1: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial
PDF: cesar-trial
Identification: 
Title:  Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial
Authors:  Giles J Peek, Miranda Mugford, Ravindranath Tiruvoipati, Andrew Wilson, Elizabeth Allen, Mariamma M Thalanany, Clare L Hibbert, Ann Truesdale, Felicity Clemens, Nicola Cooper, Richard K Firmin, Diana Elbourne, for the CESAR trial collaboration
Location: UK-based multi-center trial
Source: Lancet. 2009 Oct 17;374(9698):1330
PMID: 19762075
Introduction:
Problem:  Does ECMO provide improved safety, efficacy and cost-effectiveness, when compared to traditional therapy, in patients with severe ARDS?
Significance: This is the first positive RCT that shows a statistically significant benefit of VV-ECMO for severe ARDS.
Methods:
Study Type: Randomized Controlled Trial
Subjects: 180 adults with severe ARDS were randomized to receive conventional management or referral to ECMO center.
Primary End-Point: Death or severe disability at 6 months.
Analysis: Intention to treat
Results/Conclusions: 



* Main conclusions: 

* 6 month survival without disability: 63% ECMO group vs. 47% conventional group.
* Quality-adjusted life years at 6 months: ECMO group showed a gain of 0.03 gain




****THE BOTTOM LINE:  EDECMO Critical Assessment:  If you need a paper to support your use of VV ECMO for severe ARDS, this is your ammunition.
 



 
Article 2:  Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO
PDF:  ANZ ECMO
Identification:
Title: Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO
Authors: The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators*
Location: Australia and New Zealand
Context:  The novel influenza A(H1N1) pandemic affected Australia and New Zealand during the 2009 southern hemisphere winter. It caused an epidemic of critical illness and some patients developed severe acute respiratory distress syndrome (ARDS) and were treated with extracorporeal membrane oxygenation (ECMO).
Source: JAMA, November 4, 2009—Vol 302, No. 17
Introduction:
Purpose: To describe the characteristics of all patients with 2009 influenza A(H1N1)– associated ARDS treated with ECMO and to report incidence, resource utilization, and patient outcomes.]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 21:00
EDECMO # 13 – Does Pseudo-PEA Exist and What Should You Do About It https://edecmo.org/pseudo-pea-emd-and-such/ Mon, 01 Sep 2014 15:04:04 +0000 https://edecmo.org/?p=1400 The 3 of us discuss all things PEA The 3 of us discuss all things PEA @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) clean 35:07
Evid-ECMO (Evidence for ECMO): Critical Analysis of the ECMO literature #1 https://edecmo.org/edecmo-journal-club-1-cpr-vs-ecpr-showdown/ Sat, 23 Aug 2014 06:00:17 +0000 https://edecmo.org/?p=1361 Zack and Joe and discuss two high-impact articles that compare conventional CPR to ECPR. Zack and Joe and discuss two high-impact articles that compare conventional CPR to ECPR.
Article 1: Conventional CPR vs. ECPR for In-House Cardiac Arrest (
CPS Chen Lancet Study)
Identification:
Title:  Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis
Authors: Chen, Lin, et al.
Location: National Taiwan University Hospital; Taipei, Taiwan
Source: Lancet 2008; 372: 554-61
ClinicalTrials.gov #: NCT00173615
Introduction:
Problem: Comparing ECPR to conventional CPR for in-hospital cardiac arrest. Prior studies that showed a  benefit of ECPR over conventional CPR may have had selection bias. Prior studies also included all causes of arrest whereas this study attempts to focus on arrest of cardiac origin.
Purpose:  Is ECPR superior to conventional CPR for in-hospital cardiac arrest of cardiac origin?
Significance:  Important paper for resuscitationists to consider when considering ECMO during CPR for in-house arrest.
Methods:
Study Type:  Prospective Observational with Propensity-Score analysis matching





* Single-Center
* 3 years
* 975 total patients; 172 patients: conventional CPR = 113; ECPR = 59




Subjects:  18-75 YOA; witnessed cardiac arrest of cardiac origin who underwent CPR for longer than 10 min. Matching based on propensity-score;




* CPR team: senior medical resident, junior residents, RT, several ICU RN's. *residents were cannulating!



Primary End-Point: Survival to hospital discharge, with sub-analysis of neurologic outcomes.
Analysis: Intention to treat
Results/Conclusions: 



* Main conclusion:

* Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin.
* Survival to Hospital discharge:

* Unmatched: 28.8% ECPR vs. 12.3% conventional CPR
* Matched: 32.6% ECPR vs. 17.4% conventional CPR






****THE BOTTOM LINE:  EDECMO Critical Assessment:



* Good study that showed a benefit of ECPR over conventional CPR for in-house arrest for short and long-term patient-oriented outcomes.
* Propensity matching method reasonably mitigated selection bias
* 3 patients in the 'conventional CPR' arm were later put on ECMO because of persistent shock > Is there an implied benefit of ECMO for the post-cardiac arrest syndrome?
* Criticisms/Confounders

* Single-Center
* Patients in the ECMO group had higher incidence of LVAD, intervention, and heart transplant.
* first documented rhythm of VT/VF (49% ECPR vs. 32% CPR) was significantly higher in ECPR group; and asystole (22% ECPR vs. 27% CPR) was higher in the CPR group: ? selection bias?
* Location of arrest/CPR may make a difference (Emergency Department vs. ICU/Operating room)
* Failed conventional CPR was defined as CPR without ROSC at 30 minutes - is this timeframe too short.  What if conventional CPR were continued for 60 min?
* No TTM or hypothermia in either group.




 
Article 2:  CPR vs. ECPR for Out-of-Hospital Cardiac Arrest (SAVE-J)
Identification:
Title:  Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hosp...]]> the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 14:17 EDECMO Episode 12 – The Nurse-Based ECMO Program at Sharp Memorial Hospital with Suzanne Chillcott RN, BSN https://edecmo.org/edecmo-episode-12-setup-nurse-based-ecmo-program/ Mon, 04 Aug 2014 00:31:59 +0000 https://edecmo.org/?p=1326 In this episode Joe talks with Suzanne Chillcott, the Mechanical Circulatory Support (MCS) Lead RN at Sharp Memorial Hospital to discuss the nuts and bolts of establishing a "nurse-run" ECLS program. In this episode Joe talks with Suzanne Chillcott, the Mechanical Circulatory Support (MCS) Lead RN at Sharp Memorial Hospital to discuss the nuts and bolts of establishing a "nurse-run" ECLS program.
Suzanne Chillcott BSN, RNMechanical Circulatory Support Lead

So you think  you want to set up the next ED/ICU ECPR program?  You think you want to do ECPR in your Emergency Department or ICU?  But where to begin? Hopefully this episode will hopefully answer many of those questions:

ECLS Program Models
Physician resuscitationists cannulate. But you need an "ECMO team" to prime the circuit, help initiate bypass, trouble-shoot the machine, and manage the patient after bypass is initiated.  But who is going to do that?  Who has jurisdiction over your ECMO program?  Well, if you are working at an institution with an active cardiothoracic surgery program, chances are you already have these roles established; and I  recommend you speak to the Chief of your CT surgery team.  But for the sake of argument lets pretend you are starting an ECMO/ECLS/ECPR program de novo. What are your options?

Well, whomever is going to do this MUST be "in-house."  In the ED, Emergency Physicians should be cannulating because we are already right there. We are running the code. We should be the ones doing the cannulation. And the same goes for intensivists in the ICU.    There simply isn't time to call in a specialist to cannulate. The same goes for your ECMO team: they must be "in-house." It would seem to make sense that perfusionists would be the first-responder ECMO team, however at many institutions (ours included) perfusionists aren't "in-house 24/7."  So there are now 3 main 'models' to address this:

* Perfusionist-based: Some facilities, usually teaching hospitals with very active ECMO programs, have in-house perfusionists.  In those cases the perfusionist is usually the "first-responder."  In some cases the perfusionists handle all bedside activities from start to finish. In other cases the perfusionists help initiate ECMO and RN's or respiratory therapists (RT's) will 'babysit" the machine when active adjustments aren't being made.
* RT-based: When Shinar and I were at the University of North Carolina Chapel Hill, we witnessed this type of program.  While the perfusionists there are doing all the heavy lifting, they have trained their RT's in supervising ECMO.
* Nurse-based: ICU nurses  are cross-trained in ECMO.  This is the model we use at Sharp Memorial Hospital in San Diego.  ICU nurses are trained in all aspects of ECMO and the ICU staffing is setup such that there is always at least 2 RN's in the SICU who are ECMO-ready.  If we have an ECPR case in the ED we call the SICU. Quickly those nurses temporarily hand-off their assignments and come to the ED.

Establishing an ECMO Program at Your Hospital
Key Players:

* CT Surgery
* Nursing
* Perfusionists
* Hospital Administration

The SMH Mechanical Circulatory Support Team

These are the key components. Of course, if you are doing ECPR in your ED then you also need an ED doctor champion.  If you are reading this, I assume that will be you. So welcome to your new role!
Who Cannulates?

* CT surgeons
* Interventional Cardiologists
* Intensivists/Pulmonologists
* Interventional Radiologists
* Emergency Physicians

The Sharp Memorial Hospital ECMO Nursing Training Program

* Staffing:

* SICU nurses must apply to be on the ECMO team
]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 28:55
Video: “Bring Me Back to Life” Conference in Montreal; October 21, 2014 https://edecmo.org/bring-back-life-conference-montreal-october-21-2014/ Wed, 16 Jul 2014 18:54:56 +0000 https://edecmo.org/?p=1294 Video Promo for the "Bring Me Back to Life" conference coming up on October 21, 2014 in Montreal! Video Promo for the "Bring Me Back to Life" conference coming up on October 21, 2014 in Montreal!
 

To Register:    http://www.bringmebacktolife.ca/

#BMBTL14

 ]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 1:02
EDECMO Episode 11 – The Paris ECMO Course https://edecmo.org/paris-ecmo-course/ Fri, 11 Jul 2014 11:01:42 +0000 https://edecmo.org/?p=1268 Highlights from the Paris ECMO Course Highlights from the 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

* Clamp on tubing
* Start slow, 2000 rpm then slowly declamp
* Start sweep at 6 lpm (or 1:1 with flow)
* Go up to the max flow you can get at first to see your max
* You want to provoke reflow
* You should be able to get big flows (6-7 lpm)
* Dial Back to 5-6 Liters or 3 L/m2 (>60% of CO is what you should be aiming to capture)
* You should be able to get to 100% sat quickly
* 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]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 35:20
EDECMO Episode 10 – “Sequencing” – Ultrasound Priorities During ECPR https://edecmo.org/edecmo-episode-10-sequencing-ultrasound-use-ecpr/ Sun, 29 Jun 2014 15:15:03 +0000 https://edecmo.org/?p=1242 ~Based on a listener voicemail message, this episode focuses on the cognitive task analysis of ultrasound during ECPR. ~Based on a listener voicemail message, this episode focuses on the cognitive task analysis of ultrasound during ECPR.
When your patient hits the door with CPR in progress, what is your ultrasound priority? Diagnostics? Ultrasound-guided line placement?  This episode of the EDECMO podcast attempts to answer that question.

pericardial tamponade due to aortic transection > ECMO save.
This is a snapshot of a patient we discussed who presented with tearing chest pain and arrested with HR 180 narrow-complex. pericardial tamponade relieved with drain placed by Bellezzo.  Still no pulses. We put him on ECMO and he was taken to the OR: he had back-dissected into his AV.  After ECMO the patient was taken to the OR where his AV was resuspended and the ascending aorta grafted.  He left the hospital neuro-intact.  In this case, diagnostic US took precedence over line placement. But this is a caveat to the usual rule that US-guided line placement is most urgent.
And here is a video clip of the tamponade:



dissection video from Joe Bellezzo on Vimeo.

 

Thanks for listening!

Hey! wait!  while you're here give us a call on the listener voicemail line! Comments, Criticisms, or Questions may be incorporated into future episodes:  1-470-ED ECMO 1 (470-333-2661).

Or leave your comments below.

 ]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 16:07
EDECMO Episode 9 – The Antithesis of ECPR: African Ingenuity! https://edecmo.org/edecmo-episode-9-antithesis-ecpr-african-inginuity/ Mon, 02 Jun 2014 06:13:40 +0000 https://edecmo.org/?p=1126 When your only option is to put the horse before the cart you focus on the basics: like history and physical exam, not ECMO! When your only option is to put the horse before the cart you focus on the basics: like history and physical exam, not ECMO! This is an exciting and unique experience! - In April 2014 Zack went to visit his brother Joshua, who is working on information technology systems in Cameroon, Africa. While there Zack had the opportunity to teach, interact with their medical community, be a guest speaker on a local radio show, and interview one of their resuscitation specialists. We've tried to include a little of each of these experiences in this episode of the EDECMO podcast.  Yes, this is a little off-topic from our usual content; but we hope you'll enjoy it.  Maybe medicine in the Third World is archaic and barbaric. Or maybe our First World medicine is just completely over the top?



Medicine and Resuscitation in the Third World
In this episode Zack spoke with Christian  Ngem, who is a Nurse Anesthetist/Anesthesiologist/intensivist in Cameroon, Africa.

Christian Ngem
Christian Ngemt, Nurse Anesthetist (Cameroon, Africa)
Nurse Training - BVH 2002-2004
Baptist Hospital, Banso - Scrub nurse 2004-2007
Nurse Anesthetist School  - 2007 - present
"End of Life" care is much different in other cultures.
"African Engineered" = African Ingenuity
Having to utilize limited resources to take care of really sick patients, they have been creatively using drugs we all know and love. For example, the concept of sub-dissociative-dose Ketamine has been going on for a long time!
Drugs:
Ketamine = "The Magic Drug"
Thiopental
Morphine
Halothane
succinylcholine
Physical Exam = I forgot what that was until I heard Christian's talk here.

ECPR is a "WASTE OF TIME!" -
While they truly believe in resuscitation, they also believe in letting go when the time is right.  Cultural perspectives play a huge role here and there is a definite emphasis on allowing death with dignity. Are we wasting time, resources, money, and effort with our Western extravaganza? Maybe we are.  Let's open the discussion!
 

Chest Tube Placement

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the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 19:20
EDECMO Episode 8 – “Prime Time!” – prepping the ECMO circuit for action! https://edecmo.org/edecmo-episode-8-prime-time-prepping-ecmo-circuit-action/ Mon, 28 Apr 2014 12:00:39 +0000 https://edecmo.org/?p=980 Priming the ECMO Circuit... Priming the ECMO Circuit...
The ED ECMO crew left the www.edecmo.org World Headquarters in May 2014 to meet with Dr. Jim Manning at the University of North Carolina Chapel Hill to do some animal experiments incorporating ECMO.  Dr. Manning is an Emergency Department attending physician at UNC-Chapel Hill and has a distinct interest in endovascular resusscitation. Specifically, Jim is working with a new catheter called the "Selective Aortic Arch Perfusion" (or SAAP) catheter in non-compressible abdominal and pelvic trauma. The SAAP catheter functions much like REBOA (resuscitative endovascular balloon occlusion of the Aorta) and we will compare and contrast those two technologies in the near future.

Dr. Manning's expertise in animal models of resuscitation drew us to North Carolina. The experience was far beyond anything we could have expected and much much more will be posted over the coming months!

Dr. Manning, Zack Shinar, Shane McCurdy, and Joe Bellezzo

The Experiments



Joe Bellezzo MD

 
"PRIME TIME!" ~Nuances of priming the ECMO circuit with Greg Griffin, the Chief Perfusionist at UNC-Chapel Hill
Greg Griffin, Chief Perfusionist - UNC Chapel Hill

The folks at UNC-Chapel Hill have a very active inpatient ECMO program. While they aren't yet doing ECPR in the ED (and we hope to help change that!), they do a lot of ECMO.  Greg Griffin has been the Chief Perfusionist at UNC-Chapel Hill for the past 3 years and has been a perfusionist at their facility for over 20 years. While in Dr. Manning's lab, Zack had the opportunity to sit down with Greg and talk in depth about ECMO, the Maquet Cardiohelp ECMO machine, and some pearls and pitfalls of "priming the pump!"
Introduction

* The ECMO circuit consists of:




* The machine: which is basically a centrifugal pump (a machine that generates forward blood flow via centrifugal force), an oxygen supply, and a water bath to control the temperature. Simple.
* The circuit: the circuit is a.) the tubing that the blood flows through, b.) a membrane oxygenator (a small plastic box that contains a membrane...blood flows across that membrane while oxygen is added to the blood and CO2 is removed), and c.) the pump head (a plastic chamber that transfers the centrifugal forces from the pump to generate forward blood flow).

* The combination of the tubing, oxygenator and pump head are also referred to as the "disposables," because they come into contact with the patient's blood, and are later disposed of.


* The cart: which is the support structure that holds all the equipment.




* Definitions:

* Priming the circuit = filling the entire circuit with fluid. Priming is done by hanging the fluid higher than the circuit and letting gravity fill the entire circuit.  At the present time, we prime with a crystalloid solution.
* De-Airing: removing all air bubbles from the circuit. The nuances of this are discussed in this episode.



The Formula One Racetrack Analogy

* When the circuit is set up and the pump is flowing, a maze of tubes seems to spread haphazardly about the machine.   What appears complicated and confusing is really quite simple:  The circuit is nothing more than a big oval tube with blood flow...]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 22:28
EDECMO Episode 7 – Dan Herr on Choosing VV Candidates and Weaning https://edecmo.org/choosing-vv-candidates-and-weaning/ Wed, 16 Apr 2014 16:02:58 +0000 https://edecmo.org/?p=983 Who should get VV ECMO and when should you take it off Who should get VV ECMO and when should you take it off
Today, I got to talk with Dr. Dan Herr, director of the CSICU at the Shock Trauma Center.



We discuss two topics: who is a candidate for VV ECMO and when you should think about weaning the ECMO.

Please leave your comments and questions below]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 17:36
EDECMO Episode 6 – On Life & Death with Peter Rosen https://edecmo.org/life-death-peter-rosen/ Fri, 28 Mar 2014 12:00:51 +0000 https://edecmo.org/?p=921 Joe talks with Peter Rosen, one of the Godfathers of Emergency Medicine, on the topic of life & death Joe talks with Peter Rosen, one of the Godfathers of Emergency Medicine, on the topic of life & death
Peter is a close friend and one my mentors throughout my training and career. I trained under Peter as a resident at UCSD and I whenever Peter is in town I try to meet up with him to talk about anything BUT emergency medicine!  He usually tries to goat me into a tennis match but I've been beat up too many times to take the thrashing anymore!

Today I convinced Peter to go on-the-record with me and talk a little bit on the topic of life and death, since the topic is so important to what we are doing with ECPR.  Peter has spent decades watching gadgets, toys, and technology come and go - and carries a very understandable skepticism toward any process that artificially prolongs life.  I'm not sure I convinced him during this session but my career goal will be to show him that ECPR works in the right patient population.

Hearing Peter talk is always fascinating and I hope to have him on regularly on the podcast.
Enjoy the Episode:]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 35:03
Episode 5 – Cognitive Task Analysis of Stages I and II of Extracorporeal CPR https://edecmo.org/ecpr-cta-stageiandii/ Thu, 13 Mar 2014 11:33:44 +0000 https://edecmo.org/?p=886 Joe and I discuss in excruciating detail how to execute Stages I and II of ECPR Joe and I discuss in excruciating detail how to execute Stages I and II of ECPR
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.]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 31:16
Steven Bernard on the CHEER Trial from Intensive Care Network https://edecmo.org/steven-bernard-cheer-trial-intensive-care-network/ Tue, 11 Mar 2014 17:24:32 +0000 https://edecmo.org/?p=876 Bernard on CHEER from ICN Bernard on CHEER from ICN Intensive Care Network run by Oli Flower and Matt Mac Partlin recorded this lecture by Steven Bernard talking about the CHEER Trial of ECPR.
Dr. Bernard's Slides

Now on to the Lecture...]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 23:38
Episode 4 – The Tactical Approach to the Cardiac Arrest https://edecmo.org/tactical-approach-cardiac-arrest/ Sat, 01 Mar 2014 22:27:38 +0000 https://edecmo.org/?p=739 In this episode we talk about how protocols, defined roles, and pre-planned choreography of a medical code works. And we also do a few things different than you... In this episode we talk about how protocols, defined roles, and pre-planned choreography of a medical code works. And we also do a few things different than you...
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 "Ch...]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 18:49
Resuscitative ECMO Interview from EMCrit.org https://edecmo.org/edecmo-interview/ Fri, 14 Feb 2014 18:36:29 +0000 https://edecmo.org/?p=174 This interview with Joe Bellezzo is what caused Scott to pursue ECLS. This interview with Joe Bellezzo is what caused Scott to pursue ECLS. the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 28:03 Episode 3 – Who the HELL do we put on ECMO during Arrest? https://edecmo.org/who-the-hell-do-we-put-on-ecmo/ Wed, 12 Feb 2014 20:31:46 +0000 https://edecmo.org/?p=408 Who Gets ECPR and Who Doesn't? This may be the hardest question we deal with when a patient arrives and ECPR is a consideration. Who Gets ECPR and Who Doesn't? This may be the hardest question we deal with when a patient arrives and ECPR is a consideration. 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:

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

 ]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 15:46
Episode 2 – The Three Stages of ECPR https://edecmo.org/three-stages-of-ecpr/ Fri, 07 Feb 2014 08:28:31 +0000 https://edecmo.org/?p=384 In this episode, Joe and Zack discuss the three stages of ECPR initiation. In this episode, Joe and Zack discuss the three stages of ECPR initiation.
For greater detail, videos, and simulations come to the ECPR Page in the tutorial section.]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 17:33
Episode 1 – An Introduction to ECMO Terminology https://edecmo.org/ecmo-terminology/ Sun, 02 Feb 2014 05:22:07 +0000 https://edecmo.org/?p=380 In this episode, Joe and Zack discuss some of the terminology and basics of ECMO and ECLS. 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.]]>
the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 7:07
Episode 0 – About the EDECMO Project and the Hosts https://edecmo.org/about-the-edecmo-project-and-the-hosts/ Fri, 31 Jan 2014 21:10:13 +0000 https://edecmo.org/?p=430 In this episode you'll hear why we started the EDECMO project and a little bit about what we hope to offer. In this episode you'll hear why we started the EDECMO project and a little bit about what we hope to offer. the EDECMO Hosts - Drs. Joe Bellezzo, Zack Shinar, & Scott Weingart clean 8:45