In this episode, Joe and Zack discuss the three stages of ECPR initiation.
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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.
Ari Kestler asks about the routine use of femoral a-lines during cardiac arrest, independent from ECMO. I always place them–the reason is I dose my epi based on diastolic BP during compressions. If they get above 40 mm Hg, no repeat epi–if they don’t give another and consider some vaso. You’ll be hearing more about this here and on EMCrit. It also radically minimizes the ridiculous hunt for a pulse when you see a perfusing rhythm.
We do exactly the same and I have more stuff coming on this exact topic. In fact, we think vascular access is so important that we have restructured how we accept ambulance patients. That is coming in next month’s episode “Tactical approach to the cardiac arrest,” which outline the choreography of our codes. Bottom line: in our ED the paramedic gurney enters the room on the RIGHT side of the hospital gurney, (as if you were looking into the room.) Immediately after the patient is moved, on backboard, from the medic gurney to the ED gurney the pants come off and both groins are splashed with betadine. A second doctor, who is not supervising the code is pre-gowned and with sterile US probe in hand. It goes like this: transfer patient to ED gurney>>pants down/cut off>>>groins splashed with betadine>>>drape down>>>US-guided arterial line. Art line done in 2 minutes. Now go get the vein!
Jeff Nowak made a great comment that his shop demands confirmation of cannula location using either US or fluoro. I couldn’t agree more…with a caveat:
Fluoroscopy would be unavailable to 99% of ED docs and, even if available (portable C-arm), it wouldn’t be practical to use it for ECPR during chest compressions. However much of the time our on-pump patients end up in the cath lab for various reasons. There we confirm cannulation placement and location, place an antegrade perfusion catheter of leg ipsilateral to the femoral artery cannula, etc, all under fluoro.
In the arresting patient your only option is US-guidance, which I highly recommend. Even with US, though, you still can’t be 100% sure that you have proper cannulation due to variations in femoral anatomy. Further, using “compressability” of the vessels becomes less and less reliable the longer CPR continues. Lastly, every effort must be made to stick the artery once and carefully massage the cannulas in without damaging the vessel. This ain’t the time to be blind-stabbing the groin like in the pre-US stone-ages!
Great comments on vascular access in arrest. I do love an art-line for CPR, but mostly use it to follow compressions (with EtCO2 as the main guide). I never thought to let it guide epinephrine, but Scott’s comment makes so much sense I’m embarrassed not having thought of it! I always felt 1mg of epinephrine every three minutes was too rough a guide, and now I’ve got something better.
Joe’s take on the logistics of vascular access in arrests arriving in ED (or any super-sick patient coming in) is great! Inspiring stuff!
Thomas, please stay tuned!!! Later this week we are releasing our next podcast episode on how we manage the logistics of the cardiac arrest…which outlines exactly how to optimize vascular access at presentation of the arresting patient. I think its a game-changer, if you are a believer in vascular access during arrest! Take a look at Scott’s podcast at http://www.emcrit.org where he outlines how to use epi in peri-arrest patients in relation to the end-diastolic aortic pressure to optimize ROSC. In addition, there is a lot more to come on dosing of epi during arrest, aortic occlusion and micro-dose epi during arrest, and more.
Thanks! Microdose epi is a life-saver (for both the doc and the patient). With the really sick patients, I tend to draw up a syring of dilluted epinephrine 10mcrg/ml and have it in my pocket as insurance. A few ml’s of that solution can usually keep a dead horse alive until you get something better going.
I\m also looking forward to your take on aortic occlusion in these settings. Both REBOA and the abdominal tourniquet has potential for keeping the circulation to the upper body where it matters in arrest.