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Resuscitative Extra-Corporeal Life Support for Cardiac Arrest (ECMO)

Joe Bellezzo, MD along with his partner-in-crime, Zack Shinar, MD have started an ED ECMO service at Sharp Memorial Hospital in San Diego. I am so jealous! In this episode of the podcast, I get to talk to Joe about how it works.

Want to hear more about all things cardiac arrest and ECPR, then come to EDECMO.org

What is ECMO?

ECMO is actually a misnomer. Extra-corporeal life support (ECLS) is probably a better term. If a catheter is placed in a major artery and a major vein (VA ECMO), the patient can be provided with full hemodynamic and respiratory support, aka cardiopulmonary bypass. If catheters are placed in two major veins (VV ECMO), the patient's respiratory status can be maintained, but without the hemodynamic augmentation. Dr. Bellezzo's shop is using VA ECMO to treat refractory cardiac arrest patients.

This is not the first attempt to use ECMO in this patient group, (see the articles in the EMCrit Hypothermia/Post-Arrest Section) but I think this is the first ED physician initiated service.

Which patients are they crashing on to ECMO?

What are the stages to placing a patient on ECMO?

Stage I-get catheters into a femoral artery and femoral vein

Stage II-exchange these catheters for the enormous ECMO catheters vias guidewire and serial dilations

Stage III-attach them to the ECMO machine, which is run by specially trained ICU nurses for the first 45-60 minutes and then by a perfusionist.

Don't you have a video?

Dr. Bellezzo was kind enough to let me post this video

If you have any questions, place them in the comments and anything I can't answer, I'll forward to Dr. Bellezzo

Update:

* Mosier on EDECMO

* Review of ECMO

Now, on to the Podcast:

Part III of Dr. Rivers' talk on Severe Sepsis

Dr. Emanuel Rivers brought the concept of aggressive therapies for sepsis down to the Emergency Department with his seminal article on EGDT published in the NEJM in 2001. We were lucky enough to get an hour of his time to do a conference call with the NYC STOP Sepsis collaborative.

I broke the ~1 hour lecture into 3 parts.

If you haven't already, check out Part I and Part II.

In Part III, Dr. Rivers discusses:

*  Protein C?

* Can you do EGDT in small community EDs?

* How do you handle the tachycardic patient with severe sepsis?

* Steroids in the ED?

* Procalcitonin?

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Audio Only Version

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The Video Podcast

Part II of Dr. Rivers' talk on Severe Sepsis

Dr. Emanuel Rivers brought the concept of aggressive therapies for sepsis down to the Emergency Department with his seminal article on EGDT published in the NEJM in 2001. We were lucky enough to get an hour of his time to do a conference call with the NYC STOP Sepsis collaborative.

I broke the ~1 hour lecture into 3 parts.

If you haven't already, check out Part I and Part III for more fun

In Part II, Dr. Rivers discusses:

* CVP and Fluid Responsiveness

* Should End-Stage Renal Failure patients get lots of fluids?

* Should we be using albumin?

* Should vasopressin be a first line pressor?

* Steroids/Etomidate (See a paper by Dr. Marik on steroids in sepsis)

Here is a pdf of Dr. Rivers' Slides

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and now the Podcast...

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Video

Part I of Dr. Rivers' talk on Severe Sepsis

Dr. Emanuel Rivers brought the concept of aggressive therapies for sepsis down to the Emergency Department with his seminal article on EGDT published in the NEJM in 2001. We were lucky enough to get an hour of his time to do a conference call with the NYC STOP Sepsis collaborative.

I broke the ~1 hour lecture into 3 parts. In Part I, Dr. Rivers discusses:

* Prehospital Antibiotics

* Comparison between the original EGDT Study and the Jones study (showing the non-inferiority of the non-invasive approach).

* Alactemic Septic Shock

Find Part II and Part III for more fun

Here is a pdf of Dr. Rivers' Slides

Get a Free Trial of EM Critical Care Journal

Click Here for a 6 Month Free Trial of the New EMCC Journal

and now the Podcast...

Right Click Here for an Audio-Only Version

Video

Three Cases of Airway Disaster

In this podcast short, Minh Le Cong discusses three airway disasters.

Case I

The first case Minh mentions is Just a Routine Operation: The Tragedy of Elaine Bromiley. Here is the incredible and saddening video:

The conclusions of the investigation and coroner's report are chilling.

Update: See  the new videos on this topic

Case II

The second case Minh mentions is the Jankowski Case from Perth in 2001.

Full PDF Transcript is Here

This case really highlights how crucial quantitative ETCO2 is at every intubation. Further, needle cric failed 3 times before someone finally grabbed a scalpel.

Case III

The final case mentioned is the Rasmussen case; the best description of the case is at an medical indemnity site: Invivo.

 

Minh's Acronyms:

Minh Le Cong

MBBS(Adelaide), FRACGP, FACRRM, FARGP, GDRGP, GCMA,GEM, Dip AeroMedical Retrieval & Transport(Otago),Cert IV TAA Senior Lecturer ( Aeromedical retrieval), JCU School of Public health Tropical Medicine & Rehabilitation Sciences Medical Education Officer - Royal Flying Doctor Service, Queensland Section

Needle or the Knife for the Cricothyrotomy

In this episode, I debate Minh Le Cong, a retrieval physician from Australia. The question is what technique should we use in the can't intubate/can't oxygenate (CICO) situation.

Throughout the podcast, you will hear reference to Dr. Andrew Heard, who has written some fantastic papers on the subject. Perhaps most pertinent is his description of the formation of a CICO protocol based on his experience with a wet sheep airway instruction lab.

Heard AM, Green RJ, Eakins P. The formulation and introduction of a 'can't intubate, can't ventilate' algorithm into clinical practice. Anaesthesia. 2009 Jun;64(6):601-8.

 

Here is the algorithm from the paper (Click for full size)

Here is his video on the cannula cricothyrotomy technique

http://www.youtube.com/watch?v=Pzf29LT6VJQ

Here is his video on the scalpel-finger-cannula technique

http://www.youtube.com/watch?v=waGiiEyzqX8

Here is a video describing why Dr. Heard prefers the 14G Insyte Catheter for Needle Cric

http://www.youtube.com/watch?v=d_k_zJEYYrE

Here is his preferred method for oxygenation through the cannula

And here is the jet ventilation video:

The paper on the use of ultrasound to find the cricothyroid membrane is quite interesting.

See my prior posts on how to perform the bougie-aided cricothyrotomy and the cric show.

One of the best things Minh expressed is the need to say OUT LOUD: "This is a can't intubate/can't oxygenate situation." Saying it out loud lets everyone in the room know, there will be no more screwing around with attempts at direct laryngoscopy.

Go to the Broome Docs Blog for more Minh Le Cong.

He is an incredible guy, expect to hear more from Minh on the podcast.

I also gave a shout-out to a new podcast, the Emergency Ultrasound Podcast.

and now the EMCrit Podcast 53...

Organ Donation in the Emergency Department

Though it may not seem as important as some of the things we do in ED Critical Care, managing the potential organ donor can lead to many lives saved. In this episode I interview Isaac Tawil, an Emergency Intensivist of University of New Mexico Health Sciences and associate medical director of New Mexico Organ Donor Services.

Here are the current standards for determining brain death

Wijdicks et al. Evidence-based guideline update: Determining Brain Death in Adults

Brain Death Checklist

brain death statement

Tips on the Exam

from Wijdicks Crit Care 2020;24:648

Mesencephalon

Need only test pupil response to high-intensity flashlight. Pupils are mid-position (4-6 mm)

Use a Magnifying Glass if you don't have a pupilometer

Pons

Corneals (cotton swab or water)

Oculocephalic-Turn from middle to the side 90 degrees on both sides.

Cold calorics-30 mls of ice water. Normal response is slow deviation of eyes towards syringe

Pain Response to nailbeds, supraorbital

Medulla

Gag reflex with yankeur

No cough during deep suctioning

Checklist from the Paper

What to Exclude

J Crit Care 2019;53:212

Here is a video of Dr. Tawil demonstrating the brain death exam

EMCrit Site Links

* IBCC Brain Death

Now on to the Podcast...

Update: A more current review of this topic can be found in podcast 128

Jeff Kline is the master of all things pulmonary embolism in emergency medicine. This is a lecture he gave on fibrinolysis for pulmonary embolism. He discusses both massive and sub-massive PE.

Here is a pdf of the slides.

If you haven't already, you should also check out the AHA PE guidelines. I have a summary and the diagrams in another post.

Fibrinolysis in Pulmonary Embolism with Dr. Jeff Kline

The lecture starts with a few non-fibrinolytic points:

* Use PERC with clinical gestalt

* You can use a high-senstivity d-dimer in ALL risk groups

* Use a d-dimer with elevated cut-offs based on trimester in pregnant patients

* A high-sensitivity CTPA is the best thing we have and a negative is negative for all risk groups

Feel free to discuss any of those in the comments

Massive PE

In the guidelines, the definition is PE with SBP < 90 for > 15 minutes

Dr. Kline basically says that if you have an SBP < 90 at any point, the patient MUST be given fibrinolysis or you better have a good reason why on your chart.

Sub-Massive PE

Here are the points Dr. Kline can state definitively:

After lytics,

* The patient will feel better

* The clot will resolve more quickly

* There will be no increase in serious bleeding (Note in the original study, 2 patients with pre-lytic ICH were coded as complications)

What he can't say yet (but he has the largest RCT going on now) is mortality reduction

So who does he think should get lytics in sub-massive PE?

* BNP >90 or Pro-BNP >900 elevation (he states BNP is his go to marker). SENSITIVE

* Troponin positive SPECIFIC

* Echo with RV dysfunction, hypokinesis, dilation

He also states a low room air pulse ox is an indicator of needing lytics.

Choice of Drugs

Alteplase-he continues heparin during the infusion. He also feels you can just give the 100 mg as a bolus if you need to.

Tenecteplase-this is what he would want to receive if he had a PE. He gives it simultaneously with LMWH.

Mentions that lytics don't destroy all of the clot they just chew away at the big ones a bit.

 

For more PE stuff see the diagnosis protocol post and the PE debate insanity.

 

This is Part 4 of the Acid Base saga. In this episode, I discuss the acid base effects of fluids and when and how to use sodium bicarbonate.

If you haven't checked out the previous episodes, you should definitely do that first:

* Part I lays out the background of the quantitative approach

* Part II puts it in mathematical terms to allow calculation of acid base status

* Part III takes you through some real world examples

* Part V specifically discusses some of the Bicarb Controversy

The Acid Base Series

EMCrit Podcast – Acid Base Ep. 7 – Bicarb Updates, Quantitative Approach, and Prof. David StoryPodcast 97 – Acid-Base VI – Chloride-Free SodiumPodcast 96 – Acid Base in the Critically Ill – Part V – Enough with the Bicarb AlreadyEMCrit Podcast 50 – Acid Base Part IV – Choose the Solution Based on the ProblemEMCrit Podcast 46 – Acid Base: Part IIIEMCrit Podcast 45 – Acid Base: Part IIEMCrit Podcast 44 – Acid Base: Part I

You may need the EMCrit Acid Base Sheet to follow along

The Acid Base of Fluids

Crystalloids will have acid-base effects by their SID and the dilution of extracellular Atot

"Balanced Fluids" are fluids with a SID just low enough to balance the dilution of the weak acid, albumin (SID of 24-28)

For the effects on a patient with altered pH, any fluid with a SID the same as the pt's bicarb will keep the patient at the same pH. If the SID is greater than the pt's bicarb, then the fluid will be alkalotic and if less than the pt's bicarb--acidotic (Intens Care Med 2011;37:461).

Hypertonic fluids are even more acidifying b/c they draw pure water into the extracellular space

Chart with a bunch more fluids is on crashingpatient.com

Sodium Bicarbonate

If not stored in glass, bicarb containing solutions leech CO2 and become not so much bicarbonate.

If given at all, should be given slowly by push over 5-10 minutes or by drip; never by rapid push

In hyperkalemia, NaBicarb isotonic is essentially a potassium-free, non-acidic fluid that dilutes down the potassium.

NaBicarb can be used as a substitute for hypertonic saline in increased ICP (Neurocrit Care 2010;13:24). They used 85 ml of 8.4% sodium bicarb infused over 30 minutes.

Articles

Best Review of the Stewart/Quant Approach to Fluids

Best Review of Sodium Bicarb Use Ever

Richard Dutton is a trauma anesthesiologist who was one of the primary formulators of the concept of 1:1:1 resuscitation.

Hear more from Rich in Podcast 30

Here he is speaking on hemostatic resuscitation.

This lecture was recorded at the EMCrit Conference 2011.