Refractory Arrest E-CPR

 

Emergent VA ECMO Cannulation

  • Right Fem Venous cannula (preferred) – 25 fr – CFV – proximal to junction with saphenous
  • Left common fem Arterial cannula (preferred) – 15 fr – CFA – proximal to SFA DFA split
  • Goal 60 min or less from collapse to on pump
  • SMAK Sheath access to CFV and CFA (can use cordis to CFV)
  • In obese, Cordis to both sites
  • SMAK = 21 ga and 4fr introducer
  • Add right radial art line and triple lumen CVC if time
  • Need to be careful with other venous access sites when going on pump – tremendous negative pressure on venous side = high risk of air embolus – even from PIV

HCMC Protocol

  • 1. Radio call to staff MD to go over checklist:
    • Witnessed arrest
    • Initial shockable rhythm or AED advised shock – regardless of what rhythm they arrive to ED in (e.g. can arrive in PEA or asystole – still candidates)
    • No sustained ROSC after difib and antiarrhythmic drug
    • Transport time ≤ 30 min
    • Age 16-65 yo
    • Suspected primary cardiac etiology
    • Have to fit LUCAS
    • No life limiting cormobidity
    • No NH residents
  • 2. Get ETA from Medic, give 2 amps HCO3, notify HUC
  • 3. Conversation b/t staff and interventional cardiology
  • Prepare Stab room:
    • Roles:
      • ECMO RN from ICU brings cart & primed circuit
      • Cannulating physician – interventional cards from home
      • ED Staff – completes additional checklist w/ EMS
      • Pitboss – ECMO start kit & vascular access (CFA then CFV) – can be semi-sterile
  • After in stab room – no more shocks or epi – goal to prioritize cannulation
  • Rapid CFA (Left) access with SMAK (or Cordis for obese) and art line sample to ECMO RN for iStat – final physiologic screening parameters 3 of 4:
    • Lactate < 17.5
    • EtCO2 >10
    • PaO2 >50 or SpO2 >85%
    • Cerebral NIRS >50%
  • CFV access (Right) – SMAK if thin or Cordis if obese
  • Heparin 5000 unit bolus
  • Intubate if needed concurrent with going on pump
  • Need to have started cannulation by 90 min from witnessed collapse otherwise they are no longer a candidate
  • Cath lab automatically activated at same time ECMO cannulation begins
  • CT head and CAP on way up to cath lab

After cannulation

  • Fluid bolus
  • Right radial art line
  • Low dose norepi (0.1 mcg/kg/min)
  • CT head and CAP
  • To cath lab walked up by ED team
  • Reassess salvagability – interventionalist can stop and declare death at this point as well

Yannopoulos Study – VF/VT OHCA refractory to 3 shocks – survival increased from 15>42% with care including cath and ECMO