C H R I S T O P H E R PA L M E R , M D A S S I S TA N T P R O F E S S O R

D E PA R T M E N T O F A N E S T H E S I A D I V I S I O N O F C R I T I C A L C A R E & E M E R G E N C Y M E D I C I N E

C O D E 3 C O N F E R E N C E 1 0 / 1 4 / 2 0 1 6

An Introduction To ECMO & Why Do YOU Care?

DISCLOSURES

No relevant financial interests to disclose

ECMO

What The Hell Are You Talking About?

Goals

• ECMO Basics • Indications • EMS involvement

Collapsed At Work…

Not Good…

The Definition of Insanity

Choose Wisely

ECMO Center

Crash ECMO Cannulation

Alive & Well

ECMO History

Now what??

ECMO 101

Advanced, temporary life support for the heart and/or lungs Allows time for organ recovery **or transplant/LVAD placement**

Similar to cardiac bypass But can be done at the bedside

Can be maintained for weeks

ECMO 101

ECMO Circuit

Venous-Arterial ECMO

“Cardiac ecmo” Venous drainage / Arterial inflow

Provides both cardiovascular support and respiratory support

Typical indications: Cardiogenic shock – MI Refractory cardiac arrest Severe cardiomyopathy Massive PE Drug OD (BB/CCB/psych meds/etc.)

Venous Arterial(VA) ECMO

Veno-Venous ECMO

“Respiratory” ECMO Venous drainage / Venous inflow (oxygenated)

Allows lung rest Small TV, prevents volutrauma/barotrauma/oxygen toxicity

Does not “fix” primary problem – buys time Indications: Inability to oxygenate and/or ventilate

ARDS from any cause – pneumonia, aspiration, inhalation Severe asthma Awaiting lung txp**

Veno-Venous (VV) ECMO

VV ECMO Concept

VV ECMO Single Cannula

Future…Ventilator Free??

Show Me The DATA!!

Cesar trial (2009) SAVE-J trial (2014) CHEER trial (2015) ~50% OHCA survival

Future trials EOLIA trial for ARDS (2018 completion target)

Complications

Bleeding Stroke (clots) Sepsis Cannula dislodgement Limb ischemia

Contraindications

Absolute Any condition that would not allow anticoagulation

Relative Advanced age Major Co-morbidities

Met. Cancer Terminal illness

EMS & ECMO Involvement

1. ECMO patient transfer 2. Bringing appropriate out-of-hospital ECMO

candidates to ECMO centers for initiation

EMS ECMO Transport – The A Team

Attention To Detail

Cannula sites Infusions Monitoring devices

Practice?? Yes…

ECMO Candidate Selection

Prime ECMO Candidates

Don’t give up! Young(ish) Relatively healthy (presumed) Witnessed arrests/short downtime

MI Arrhythmias Tox/Overdose Drowning (cold) or hypothermia Asthmatics Pulmonary embolism

Call ahead Earlier placed on ECMO the better (<60 min)

ECMO Survivor

My Hope for the Future…