Out of Hospital ECLS (Extracorporeal Life Support)

[usafmedic45]

BTW USAFmedic, I don't know anyone who uses cut down in adults for ECMO, it's all percutaneous. I've only rarely had to use ultrasound to get the needle in (morbidly obese patient or odd anatomy).

Most of my experience with ECMO has been in peds and even then it's very, very limited. I'll freely admit that I'm not the first one you want to go for management of one of these units. I'd probably fare better with gaining access than I would with management.

 

[silver]

Thanks for having me, I appreciate you all not minding the intrusion.

"If you had carte blanche to conceive the most feasible way possible to get someone onto artificial circulatory support in an austere environment (with or without oxygenation), what would it be?"

You know, honestly I think I'd have to agree with USAFmedic, and not bother doing it. It takes considerable time to place two cannula for Veno-arterial ECMO properly even under good conditions and it helps if the patient is already in an ICU environment (entering a larger artery on full anticoagulation should make anyone pause).

No it doesn't necessarily take a cardiac surgeon to cannulate (I know pediatric, general, vascular, and trauma surgeons who do), but again fracturing a large vessel and the amount of bleeding that could occur--and remember the patient is fully anticoagulated isn't something a non-surgeon would want to or have the ability to deal with especially not in an austere environment. However, cannulating in Forward Resuscitative Surgical Suite or forward deployed military hospital would be acceptable. Again the equipment is available to deal with a surgical intervention if necessary.

It's interesting that the military has become very interested in ECMO for severe acute respiratory failure lately. And there have been some technical advances that are making ECMO more attractive like the CardioHelp http://www.youtube.com/watch?v=ozWZ1iNAMWc and

The Avalon Bi-caval DLC http://avalonlabs.com/animation/animation.html (this one DEFINITELY requires placement by an experienced surgeon in an OR under fluoroscopy--trust me, don't let anyone tell you different).

The great thing about these two is that the first makes moving a patient much easier, the second gets the cannula out of the groin and allows for early mobilization. There are places that walk their patients on ECMO, and alot of places are keeping their patients lightly sedated or even awake.

BTW USAFmedic, I don't know anyone who uses cut down in adults for ECMO, it's all percutaneous. I've only rarely had to use ultrasound to get the needle in (morbidly obese patient or odd anatomy). You are also correct that most ECMO teams aren't run by surgeons (where I trained it was, and I think this worked well for reasons I won't go into). The key to ECMO isn't inserting the cannula but the critical care over the next few days to weeks.

To comment, the skills aren't necessarily exclusive to surgeons, rather any interventionalist (radiology or cardiology) can do it. Its just a skill that takes practice, confidence, and a bit of finesse. Additionally, one of the articles states cutdown was used for access. It also states that the patient was severely hypovolemic and was difficult to cannulate. It, however, does not state whether or not cutdown was attempted after failed percutaneous attempts.

Someone asked about products to keep circulation going with or without oxygenation and to just keep the novelty going I give you this:

Impella
http://www.youtube.com/watch?v=ictLYH21eXY
Used in patients with severely reduced cardiac output (low ejection fraction) from cardiogenic shock/heart failure. Placed as a way to temporarily assist the heart. I know it has been used in patients with cardiogenic shock secondary to AMI, but haven't seen it done. Again this needs to be placed under fluoro.

 

[mycrofft]

I like the "austere environment" concept, thanks!

So doc does "pump head" have bearing on this discussion?

 

[Brandon O]

I did have LVADs in mind but I have a hard time imagining someone doing this in the field.

 

[usafmedic45]

I did have LVADs in mind but I have a hard time imagining someone doing this in the field.

Yeah, that's totally out of the question. LOL As a very wise trauma surgeon once told me, "Never open a chest unless you really want to deal with whats in there."

 

[mycrofft]

Roger that.

As I recall, we have periodically had people advocating, or telling us about their services' protocols allow, field thoracotomy, and a British article was cited once.

 

[RocketMedic]

Field thoracotomies sound like a complete recipe for disaster, to be honest. Barring truly unique situations like impalements unable to be cut/disconnected, I can't ever think of a reason to open the chest for a lot of reasons in a prehospital setting.

1. Infection. My alcohol, peroxide, iodine, Betadyne, soap, and Cavi-Wipe do not equal a sterile field, nor does an OB kit.

2. Where the heck do I put the organs that spill out/etc?

3. Why would I waste time on an unstable patient to crack the chest, and what benefit does it serve, as opposed to the massive risks?

4. I doubt that the survival benefits gained from prehospital thoracotomies counters the massively increased risk of horrific septic death.

5. I do not have the training required. Ties in with 'lack equipment' and is beaten by 'doesn't have a good reason."

Thoracotomies are something avoided by many doctors in ERs because they're complicated and it's not in the patient's best interests to be opened up by people that don't know exactly what they're doing, why they're doing it, and how to do it.

 

[usafmedic45]

Where the heck do I put the organs that spill out/etc?

I think you're confusing the chest and abdomen. Unless the patient is well beyond salvage, nothing should be "spilling out of the chest".

Why would I waste time on an unstable patient to crack the chest, and what benefit does it serve, as opposed to the massive risks?

Theoretically, it may be the only way to get a patient with massive vascular trauma to the thorax or abdomen to the OR alive. Correctly done, a thoracotomy honestly is quicker than most IV starts. It's not a lengthy procedure at all....well, not the actually thoracotomy part.

it's not in the patient's best interests to be opened up by people that don't know exactly what they're doing, why they're doing it, and how to do it.

Honestly, I would tend to agree with you there. The ONLY surgical procedures I could see being feasible in the field are surgical airways (and I look at those much the same as an IV on the scale of difficulty), chest tubes* and perimortem C-section in a moribund or arrested late third trimester patient.

*- only in services with long response times and highly skilled medics

 

[Brandon O]

Honestly, I would tend to agree with you there. The ONLY surgical procedures I could see being feasible in the field are surgical airways (and I look at those much the same as an IV on the scale of difficulty), chest tubes* and perimortem C-section in a moribund or arrested late third trimester patient.

Do you know of anyone out there field C-sections? I only know the old story of the crew in Jersey who lost their licenses that way.

I might add to your list pericardiocentesis and escharotomies... which I do know of flight/CC crews undertaking some places.

 

[usafmedic45]

Do you know of anyone out there field C-sections? I only know the old story of the crew in Jersey who lost their licenses that way.

I have heard of a few isolated cases here in the states and heard of it being on the "table" so to speak with the German Notarzte (emergency physicians) of the DRK, etc. Our medical director theoretically approved it (as a supervisor level, medical control authorization required skill), but it was not ever actually used (thank G-d). I've witnessed two in the ED however and in both cases the mother and baby both survived.

I might add to your list pericardiocentesis

It's such a generally low yield issue and the diagnostics of it are far from ideal unless you have ultrasound in the field (read as: cost prohibitive). Without diagnostic imaging, you wind up with far more false taps than anything else. If I had my way and was honestly certain I the patient had tamponade, I wouldn't screw around with a pericardiocentesis. I would go straight for a subxiphoid window.

escharotomies

Point taken, although I would limit it to the neck and chest. We have no good excuse for doing decompressive escharotomies of the limbs in the field.

 

[Brandon O]

I have heard of a few isolated cases here in the states and heard of it being on the "table" so to speak with the German Notarzte (emergency physicians) of the DRK, etc. Our medical director theoretically approved it (as a supervisor level, medical control authorization required skill), but it was not ever actually used (thank G-d). I've witnessed two in the ED however and in both cases the mother and baby both survived.

Were these maternal arrests, or for other reasons?

It's such a generally low yield issue and the diagnostics of it are far from ideal unless you have ultrasound in the field (read as: cost prohibitive). Without diagnostic imaging, you wind up with far more false taps than anything else. If I had my way and was honestly certain I the patient had tamponade, I wouldn't screw around with a pericardiocentesis. I would go straight for a subxiphoid window.

I know that at least one of the local HEMS services does pericardiocentesis, and I know that they do have ultrasound to diagnose and guide it. But they fly with a doc, for whatever it's worth.

Point taken, although I would limit it to the neck and chest. We have no good excuse for doing decompressive escharotomies of the limbs in the field.

Agreed.

 

[usafmedic45]

Were these maternal arrests, or for other reasons?

One was fully arrested and one was about to. Both had massive hemodynamic improvement as soon as the parasite was removed.

I know that at least one of the local HEMS services does pericardiocentesis, and I know that they do have ultrasound to diagnose and guide it. But they fly with a doc, for whatever it's worth.

It's not a hard procedure to do- even blind- but it's just making the decision that's the issue. Which program out there flies with a doc all the time?

 

[Handsome Robb]

One was fully arrested and one was about to. Both had massive hemodynamic improvement as soon as the parasite was removed.


It's not a hard procedure to do- even blind- but it's just making the decision that's the issue. Which program out there flies with a doc all the time?

Our flight program does them blind. Watch for ectopy on the monitor! haha If they start throwing PVCs you've gone too far.

 

[usafmedic45]

Our flight program does them blind. Watch for ectopy on the monitor! haha If they start throwing PVCs you've gone too far.

Like I said...the problem isn't with the stick....it's with the ability to accurately diagnose when you have a tamponade. The signs we are all taught to look for tend to have a rather piss poor specificity and sensitivity. The services I got to handle CQI for as far as chart review goes had a nearly 60% negative tap rate. Of course, you're talking a whopping total of 25 or 30 pericardial taps in a year over a medical control oversight involving several services.

 

[mycrofft]

Isn't there an electrical means to tell when you have contacted the pericardium?

Like clip lead I to the needle and watch the signal? Or did Hawkeye and Col Potter do that?

And, organs come tumbling out....like with a torn diaphragm?

 

[systemet]

As I recall, we have periodically had people advocating, or telling us about their services' protocols allow, field thoracotomy, and a British article was cited once.

http://www.ncbi.nlm.nih.gov/pubmed/21131854

I think this is the article, which describes the outcomes of 71 field thoracotomies over fifteen years performed by London's HEMS physicians (anesthesiologists and EM). They had 13 survivors, all presenting with tamponade, and all were performed on patients in cardiac arrest from penetrating trauma.

* I'd be surprised if anyone is doing this in a non-physician based EMS system.

* However, it makes you wonder if pericardialcentesis should be performed more often in penetrating trauma arrests. Relatively few systems allow paramedics to use this skill. Of course pericardialcentesis =/= thoracotomy + myocardial repair.

Random anecdote: A colleague of mine once transported a guy with a midline stab wound who coded en route. The chest got opened in the ER, and they literally stapled the myocardium. He was very impressed. Oddly, I don't recall whether the patient survived.

 

[usafmedic45]

Like clip lead I to the needle and watch the signal? Or did Hawkeye and Col Potter do that?

And, organs come tumbling out....like with a torn diaphragm?

Even with a survivable diaphragmatic hernia, you're not normally going to get the "Night of the Living Dead" style pile of organs falling out of the chest. Hell, we don't even really see that at autopsy following plane crashes. Although....there was that one where you could feel the heart rolling around in his chest as you moved him onto the table....

 

[Brandon O]

It's not a hard procedure to do- even blind- but it's just making the decision that's the issue. Which program out there flies with a doc all the time?

Lifeflight out of UMass Worcester.

 

[ECMODoc]

"To comment, the skills aren't necessarily exclusive to surgeons, rather any interventionalist (radiology or cardiology) can do it. Its just a skill that takes practice, confidence, and a bit of finesse. Additionally, one of the articles states cutdown was used for access. It also states that the patient was severely hypovolemic and was difficult to cannulate. It, however, does not state whether or not cutdown was attempted after failed percutaneous attempts."


(Sorry, I haven't had time to figure out how to do those "quote" boxes yet)

Again, I want to emphasize that it's not the skills needed to place the cannula (I'm sure you guys might have picked up the skill as fast or faster than me), but rather the skills needed to deal with a serious iatrogenic complication that are most important.

Regardless of volume status I still don't believe cut down is necessary in the majority of cases to gain access in the adult for ECMO cannulation. Honestly, I think it would make it more difficult to place a large cannula. A number of the patients I've treated were hypovolemic (but I have not read the paper you reference, and don't know how volume depleted the patient was, or the situation, I can only talk about my experience). I can tell you that I've placed 31Fr Avalon cannula in the right IJ percutaneously using fluoroscopy.

For neonates cut down is still used by most pediatric surgeons, although there have been a few who argue for percutaneous cannulation. Nothing like trying to control a moving vessel when the kid is turning dark blue.

 

[ECMODoc]

"So doc does "pump head" have bearing on this discussion?"

You mean as in cognitive impairment after ECMO? That's a really interesting question in the adult.

I have a fantastic story, but because of HIPAA I really couldn't tell it in this forum since adult ECMO is done so rarely.

I can say there was a great outcome on a very high functioning individual, with no known cognitive dysfunction. But that's a study I'd like to do in the future. It would just be difficult to accurately measure cognitive function before and after.

Most of the adult patients have done very well. And I wonder if any dysfunction was due to hypoxemia before going on pump rather than anything caused by the circuit. Remains to be seen.