EDECMO Podcast

In ep. 36, 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      

…all acute injury to the heart is reversible.   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!

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is used to gain proximal control over non-compressible hemorrhage below the diaphragm.  The concept has been covered extensively in social media. 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, REBOA guru who teaches the REBOA modules at our endovascular resuscitation conference, REANIMATE. Do you want to learn how to aggressively manage the crashing trauma and medical patients using ECMO, ECPR, REBOA, ultrasound  and advanced resuscitation techniques?   REANIMATE 4 is September 21-22, 2017: http://reanimateconference.com/register/ References 1. Norii T, Crandall C, Terasaka Y. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg. 2015;78(4):721-728. [PubMed] 2. Johnson M, Neff L, Williams T, DuBose J, EVAC S. Partial resuscitative balloon occlusion of the aorta (P-REBOA): Clinical technique and rationale. J Trauma Acute Care Surg. 2016;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S133-S137. [PubMed]

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  

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. 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:    

In this episode we change direction a bit and 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.   Guests on this show: Jenelle Badulak MD Critical Care Fellow University of Washington Dr. Henrik Vase Interventional Cardiologist Aarhus University Hospital, Denmark      

Is There EVER a Role for Veno-Venous ECMO (VV-ECMO) in the Emergency Department? Here is a case of a young man who presented to our Emergency Department in June, 2106 with profound anaphylaxis. This was a rare “CAN Intubate/CAN’T VENTILATE” scenario: 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

Deirdre Murphy, a critical care expert at Alford Hospital, dives into the intricacies of post-arrest ECMO management. She emphasizes monitoring vital metrics like oxygen saturation and end tidal CO2 for optimal recovery. The conversation shifts to volume status management, detailing fluid balance complexities. Deirdre also discusses ventilation strategies, underscoring the importance of adjusting CO2 levels and managing anticoagulation. The chat wraps up with a holistic view on care post-ECPR, stressing the need for a comprehensive approach to patient recovery.

Torvind Næsheim     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:      

The University of Utah 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