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…

 “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.

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 transition pore. 2.) RIC causes release and transport of micro-RNA-144 from the ischemic limb.  Amongst other effects, miRNA-144 effevely down-regulates protein expression involved in apoptosis, autophagy, and survival signaling. Supernerds, if you really want more on this:

Przyklenk Basic Res Cardiol 2014 RIC microRNA

role of mitochondria in protection of the heart by preconditioning Halestrap 2007

[email protected]

@grahamnichol

Graham is an avid cyclist and attributes his ability to ride more than 100 miles and climb more than 10,000 feet in a day to his off-label use of remote ischemic conditioning!  Here, he and a friend are about to begin the long ride up Carson Pass to finish the Death Ride.

CastleFest: April 14-16, 2015

CCUS Montreal: May 1-3, 2015

SMACC Chicago 2015: June 23-26, 2015

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.  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:

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.

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!)

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?

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:

-physician on ambulance

-“Exactly like trauma room”

– 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

– 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. Lionel says that this approach is actually faster and safer than just blindly stabbing around with the needle as is done with a blind percutaneous method. 

– Physician on scene makes assessment

– Positive bystander of CPR

– Younger people

– Shockable rhythm better

– Out of hospital cardiac arrest survivorship should be the same as In-hospital cardiac arrest

– Need to decrease low flow state (shorten the time patients need chest compressions by getting them on the pump ASAP)

– 20 minutes to bypass in the field from arrival of prehospital ECMO team

– This gives you bypass of less than 60 minutes

– “Load and Go” is not fast enough

– 10% survival from prehospital ECMO

– ECMO is a “Bridge to Neurologic Assessment”

– Organ Donation

(*photos courtesy of Lionel Lamhaut)

Successful treatment of refractory cardiac arrest by emergency physicians using pre-hospital ECLS

Safety and feasibility of prehospital extra corporeal life support implementation by non-surgeons for out-of-hospital refractory cardiac arrest

EDECMO 14: The CHEER Trial with Dr. Stephen Bernard

EDECMO 15: Part 2 of our interview with Dr. Stephen Bernard

INTENSIVE: The Alfred Hospital’s amazing ECMO site

In this episode, Zack and Joe talk with Dr. Cyrus Olsen, Oxford graduate and expert in bioethics about how to decide when to “Stop the Train”.

“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

“How young is too young…” to withhold resuscitation?

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

Utstein Variables for CPR

 The Life Matrix and the Functional Threshold:

“We cannot predict the neurologic outcome of patients that are in cardiac arrest” – Zack Shinar MD

Bottom line: As a resuscitationist in the Emergency Department you MUST err on the side of aggressive curative care, unless there is compelling evidence to do otherwise.  You are on ethical solid-ground to approach resuscitation in this fashion. But…you will fuck this up. And that’s ok if your heart is in the right place. And once you realize that your patient does not belong in the AGGRESSIVE CURATIVE arm, you begin AGGRESSIVE PALLIATIVE care. In either case, you care is MAXIMALLY AGGRESSIVE.  

Dr. Olsen is a graduate of the University of Oxford and is now an Associate Professor at The University of Scranton, in Pennsylvania where he specializes in Ethics and Theologic Studies. He has published extensively in the arena of medical ethics and sits on the IRB (Institutional Review Board) for both human and animal studies at his institution. A graduate of the Comparative History of Ideas Program at The University of Washington, and Systematic Theology from The University of Oxford, his research and teaching address many aspects of human studies and bioethics.

Circulation- Ethics of CPR

Ethics of Resuscitation – Hayes

Freedom from the Tyranny of Choice

Br. J. Anaesth.-1997-Mohr-253-9

1. Emcrit Podcast 25: End of Life and Palliative Care in the ED – Scott Weingart from the Emcrit Podcast

2. Emcrit Podcast 93: Critical Care Palliation with Ashley Shreves

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. Just days after we published our initial 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.

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:

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. ECMO was established in 24 (2 patients in the OHCA arm were pushed through the protocol but didn’t actually go on pump; one was cannulated but achieved ROSC prior to going to cath lab and therefore was not put on bypass, and the other patient had a failed cannulation attempt but was taken to the cath lab anyway (presumably on Autopulse) and survived. Both OHCA patients and IHCA arrest patients were grouped together in their outcome data. ROSC (return of spontaneous circulation) was achieved in 25 (96%) patients. 13/24 (54%) were able to be weaned from ECMO support and survival to hospital discharge with full neurological recovery (CPC score 1) occurred in 14/26 (54%).  These are remarkable initial results that higher than what we’ve seen in larger studies.

Talking points:

Study after study has shown that the single biggest key to the success of ECPR is the time to initiation of bypass. So in this trial, the rapid transport with Autopulse and rapid activation of the ECMO team optimized this interval.  But we believe the success of this study would not have been possible without ECMO as the final bridge that could make all this happen.  To highlight this concept, on October 14, 2012 Austrian skydiver Felix Baumgartner jumped from the Red Bull Stratos capsule 24 miles above New Mexico, USA and broke  3 World Records: a.) Exit Altitude (24.2145 miles) b.) Maximum Vertical Speed (843.6 mph) and c.) Vertical Distance of Freefall (119,431 ft). And he broke the sound barrier.

Advancements in technology, human transport, a willingness to push the envelope, and huge set of balls, made that happen. But that couldn’t have been done without a relatively simple device that has been around for decades that allowed Baumgartner to land on his feet: the parachute – a device that “bridges” the skydiver from potential free fall-death to soft landing with proper deployment.  ECMO can be thought of as one such device.

Update 10/25/2014 Hot off the press: Google Senior Vice-President Alan Eustace one-upped Baumgartner on October 24th when he jumped 135,890 ft from a helium balloon to become the World-record holder for highest parachute jump. Additionally, Eustace used no corporate funding and did not use a capsule, opting instead to be carried into the stratosphere in a space suit alone. Here are some photos of that:

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— ED ECMO Project (@edecmo) October 13, 2014