EDECMO Podcast

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   Learning Points: RUSH exam early for undifferentiated shock Restrictive lung strategy to avoid ARDS Multi-agent OD: contact Poison Control – they can actually help! 1-800-411-8080 ECMO is a bridge to metabolism/recovery. “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.” – Dan *and special thanks to Dan McCollum for creating and sharing the Napoleon Dynomite memes.

CHRIS HO VS JOE BELLEZZO – ECPR IS A STEP TOO FAR ***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:

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.” 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

In this episode, Zack interviews Jim Manning MD (University of North Carolina) and Dr. Lionel Lamhaut of the famed French SAMU (Service d’Aide Médicale Urgente). 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…        

The Rat Pack: The Last Year of EDECMO!

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, @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. 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?  

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

  …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. You can know more about hemodialysis services here. Mitochondrial and Cellular Respiration Poisons (dinitrophenol & Cyanid) and Carbon Monoxide? ECMO is of NO USE in these intoxications.

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 Pine Club Golf 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

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