EMCrit Wee – A Case to Threaten Current ECMO Evidence from Sam G

Over at EDECMO we talk about the huge benefits of ECPR demonstrated by the fact that there are neurologically intact survivors when ECMO is initiated at the point of cessation of standard ACLS. But what if standard ACLS had not stopped… What if you just kept going?

Mirroring Cliff Reid’s amazing talk: When Should We Stop Resuscitation?, I present Sam’s case.

 

From Sam G:

I just experienced probably the most amazing case I’ve ever been a part of this past Monday.     This case has become the talk of the place, as it was very controversial within the world emergency medicine, critical care and cardiology here @ Janus General.  It was discussed in M&M and there is gonna be a joint multidisciplinary thing, etc.  But otherwise there is no one else’s opinion I would be more interested to hear than yours, so I wanna share it with you:

I was working shift in Major Treatment Area here at Janus General, and we hear we’re getting a med resusc… rolls in a guy looks to be in about his 60’s (turns out he was 59).  Story was :

Witnessed Arrest with bystander CPR… shockable for EMS, but shocked 6-7 times… meds given were for some reason only bicarb and Lidocaine (not sure why?)

I will share with you my documentation, only b/c it will save me tons of typing and I trust sending it to you..

This patient was seen in the resuscitation bay along side Dr. XXXXX concurrently.  This patient presents status-post witnessed cardiac arrest after return of spontaneous circulation.  His rhythm was always shockable per EMS.  He arrived with a King airway in place.  There was a large air leak noted.  CPR was in progress shortly after arrival as he was noted to not have pulses.  Chest compressions were resumed immediately and multiple rounds of CPR with multiple rounds of epinephrine, and medications including amiodarone, bicarbonate, calcium, magnesium were administered.  Please see nursing medications charting.

Multiple echocardiographic images were obtained by myself.  Please see computer for images.  The patient was noted to be in and out of ventricular fib.  CPR was continued in line with ACLS protocol.  The King Airway was removed and endotracheal intubation was performed by myself using a MAC 4 blade and an 8.0 endotracheal tube without difficulty.  There was good condensation on the tube, good chest rise, and end tidal CO2 was detected immediately with excellent wave-form.  Intra-code bedside echo was performed and revealed no evidence of right ventricular enlargement or strain on echo, or any other signs of massive pulmonary embolism.  There was also no pericardial effusion.  Echo did show akinesis/hypokinesis inferiorly and somewhat laterally as well.  The inferior wall was essentially akinetic.   Anterior wall motion was clearly preserved.  This was best seen on the parasternal long and short axes.

There was very high suspicion for acute coronary event.  Furthermore there was no evidence of hypoglycemia, hyperglycemia, hypokalemia, hyperkalemia.  The patient’s pH was noted to be significantly acidotic, and 2 additional ampules of sodium bicarbonate were administered at that time.  There was good sliding bilaterally on ultrasound.  There was no evidence of massive pulmonary embolism on echo, and there was no evidence of pneumothorax.  Intravenous fluids were pressure bagged in.  There was no significant hypothermia.   End tidal was difficult to interpret due to multiple ampules of sodium bicarbonate.  After nearly 45 minutes of aggressive CPR the decision was made to use thrombolytics because we felt strongly that this was an acute myocardial event, it was also strongly felt that without thrombolytics stabilization and termination of electrical storm could otherwise not be accomplished, in order to get this patient to the cath lab.

The decision was made to was give teneceteplase intravenously, as again, stabilization and return of spontaneous circulation continued to only be transient.  It was felt that the patient could not be stabilized for cath lab intervention, and this was our last resort. Following the administration of TNK, the patient did not have any further episodes of v-tac/fib/pulselessness.  EKG finally obtained after termination of storm revealed injury pattern in inferior leads II, III, and aVF.  There was evidence of left bundle branch block, however there was severely excessive DISCORDANCE in leads 3 and aVF.  Elevation was 7 or 8 mm,greater than 5mm being concerning for STEMI, and also of note far greater than 25% of the S Wave.    Lead II showed excessive CONCORDANT ST Elevation of multiple mms, far surpassing the 1mm requirement of Sgarbossa’s Criteria. These findings of inferior coronary artery distribution involvement correlated excellently with the wall motion abnormalities noted on echo . Code STEMI was called, and code cool was initiated as well.  The patient was placed on norepinephrine drip.  The patient was also placed on amiodarone drip. This case was discussed at length with critical care and cardiology attendings at the bedside.

Cardiology felt that since thrombolytics were given, Cath Lab was not indicated at this time.   Of note, it was contemplated to cease efforts, however since this was a witnessed arrest with immediate CPR, and the rhythms were always shockable, the decision was made to continue efforts.  As the patient was in dire straits, it was felt that benefits outweighed the risks of bleeding, and it my sincerest hope that the thrombolytics  benefit the patient for his  highly suspected STEMI.    The patient was admitted to the intensive care unit in very critical condition.

So…

We weren’t able to get an EKG until well near the end of the code, bc he would revert right back to v-fib after transient ROSC… he did this the entire code..  I might have stopped if it wasn’t for the resident, Dr. Karina Reyner, insisting that she was not comfortable calling it as the patient was still shockable…we discussed the increasing likelihood as the code went on of bringing back the heart but not the brain … well, she asked “why not just push lytics?” …. My philosophy is I will not run a half-ass code… if the code is running it’s all or nothing, I figured this was 1. witness with immediate CPR 2. He was consistently in a shockable rhythm… and  3. knew the CPR he got for the past 45 minutes was excellent.. the tech’s were doing amazing compressions.. (in fact we broke his sternum) ..so –we pushed lytics…   After lytics were pushed the storm relented and the patient had no further episodes of V fib/tac…

It’s crazy that he got lytics at a cath center w/one of the best door balloon times in the nation… weird and interesting concept… I know he would have not made it without lytics though… cards doesn’t take CPR in progress patients, and when they came down, I was shocked at the overwhelming resistance, even before they knew we pushed lytics…  there was not only resistance to taking the patient to cath, but even questioning the diagnosis.   I was amazed at the response… this is despite clinical picture, hx, EKG, and Echo all pointing to a diagnosis of nothing other than STEMI.

Overall, we got a lot of shit from both Cards and Crit Care for pushing lytics at a cath center… but here’s the most amazing part of the story, and what makes it such a big deal:

Patient was following commands a few hrs later in the ICU… (ICU doc called down to tell us)… he did have a GI bleed, but that did resolve without surgical intervention.  He was extubated w/in 24 hrs.. A-line removed.. His GCS is 15.  I went and saw him yesterday and he was very tearful and appreciative… kept saying “so humbling…”  “I guess it wasn’t my time…”  He has picts on the wall in the ICU of his granddaughter an was saying how he gets to see her again…

This case is amazing for so many different reasons, but.. the obvious is lytics given for suspected STEMI @ cath center…

Should lytics be pushed intra-code with refractory and electrical storm even if at a cath center?

Also interesting that we didn’t give him 9 to 15 doses of Epi as ACLS would call for…  I have a feeling this would’ve crushed his chances as well…

Anyway I have attached the EKG’s… 1st one was the only one done in the ED.  The remainder were when he was upstairs… Cards Echo’s showed exactly what mine did.  Trop next day was >100… but he made it and is doing stellar.

I will send the Echo clips as well… amazing that you can see the wall motion abnormalities even when he is in Vtac/Fib…

This is by far the longest CPR to make it neuro intact that I’ve ever experienced… Dying to know what you think about all the pertinent issues!  Let me know if you have any other questions about the case…Thanks so much..

 

Scott- I think a wee about this would be awesome.  There just are so many critical issues to discuss, like:

  1. Should we maybe be lysing more cardiac arrest STEMI’s (whether you have a pre-hospital confirmatory EKG, or strong evidence to suspect), despite being at a cath center?
  2. If you do lyse and the patient attains and maintains ROSC, shouldn’t these people get cath still?
  3. Does TNK vs other lytics play a big rule?  We have TNK here b/c of Kline, and I have pushed it one other time earlier in the year on a crashing pt with high clinical suspicion, and u/s showing everything (Huge Rv, Huge Ra, flattening, paradoxical motion, McConnel’s) and this guy stabilized after a few hrs, got a repeat cardiology echo that was read as  normal, got a follow up ct that showed b/l PE’s… and was d/c’d after a short stay of only 4-5 days.  It just makes me wonder how much of a difference other lytics would/wouldn’t make.
  4. When do you stop CPR?  Our patient had end tidals that were like 30’s or 40’s or so I believe, but he also got prehospital bicarb, and then 3 additional total amps by us… but even in the absence of bicarb admin, I don’t know of any evidence showing that a higher end-tidal means don’t stop…  (versus saying less than 10 with 20 mins of CPR  you can basically stop)
  5. I am also convinced that if we slammed him with epi every 3-5 minutes, that he wouldn’t have made it neurologically intact… possibly another point of discussion.
  6. This wasn’t as much of a problem for us b/c the patient would convert with electricity, (end-tidal spike) as well as after the 2 mins of continuing right back on the chest after the shock, he would be in a perfusing rhythm (junctional, etc)… and then quickly revert back… Buuuut- Amal shared with me an extremely interesting idea that I had not heard of, and he says they are doing this at Maryland, and the medics are doing it in the field as well (no great evidence), but putting 2 defibrillators attached to the patient (4 pads), and shocking at 720J!. (double-sequential defibrillation)

Anyway- I’m sure there are more issues as well, but obviously the biggest in our case is lysis, intracode, cath center, cath after lysis, etc

If you have any more questions or want any other info about our case let me know.  Looking forward to this!

 

This is just one of many echo clips from this case. The Ultrasound Podcast guys will be doing an episode with Sam on intra-arrest echo to discuss these clips further.

Initial ECG

Initial ECG

Play

You finished the 'cast,
Now get CME credit

Not a subcriber yet? Why the heck not?
By subscribing, you can...

  • Get CME hours
  • Support the show
  • Write it off on your taxes or get reimbursed by your department

Sign Up Today!

.

Subscribe Now

If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the ED Critical Care goodness.

This Post was by , MD, published 3 months ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.

Comments

  1. Ok. Its on and the gloves are off!!! (kidding)

    First: Great case and great resuscitation! This stuff is what its all about!!

    Now for my thoughts: I admit that I am inherently biased since I’m the EDECMO guy and have seen so many patients fail ACLS (usually after 60+ min of traditional CPR), go on pump as a bridge to an intervention, and survive neuro intact. With that disclosure: Intra-arrest lytics are a reasonable salvage option IF you are dealing with an occluded coronary or massive PE, but there are other causes of arrest that aren’t thrombo-embolic. And once you’ve pushed the lytics you have trashed any chance of ECMO – the massive catheters in the femoral vessels would hemorrhage after lytics. So you better be damn sure you are looking at an MI or PE before pushing lytics – and I totally agree that there was enough evidence in this case to support doing exactly what you did. Further, Lytics may be your ONLY salvage option if ECMO isn’t a tool in your shed. In fact we had a PE arrest (with refractory VF) where we had to make that exact decision (lytics vs ECMO). As you might expect we put the pt on pump (instead of lytics) and she did wonderfully – 100% neuro recovery.

    …but just be careful – not every arrest case is thrombo-embolic! Just for argument’s sake, here are some examples: we had a hypothermic arrest in VF where the bridge to recovery was ECMO and rewarming. What about the amniotic fluid embolus?. We had an aortic dissection/transection ECMO save. And there is the massive B-blocker OD. These patients were dead without ECMO and lytics wouldn’t made things worse.

    On a final note, most of these prolonged arrests suffer the “Post Cardiac Arrest Syndrome” and have stunned hearts. They are often profoundly weak – in our experience we have seen full recovery of hearts that had EF’s in the single digits for the first several days. ECMO initially bridged them to their entervention but ECMO was the ONLY thing that kept them supported until the myocardium recovered from the hit.

    Great case Sam. You saved this guy’s life. And there is nothing better in whole World than doing exactly that.

    ~Joe

    • OK ECMO boy, here is a ? for you. Pt gets intra-arrest lytics and gets ROSC. At some point post-arrest, pt starts to decline with pressor resistant shock. How long post-lytics would you feel safe placing the cannulae?

      • samghali says:

        Hi Joe,

        Thanks for your comments.

        I just first want to say that I gotta give a lot of credit to the resident working with me on the case who did a fantastic job- Dr. Karina Reyner (an amazing resident and person!)

        Agreed- this kinda stuff is why we do what we do!

        I totally agree that there is no doubt that intra-arrest lytics are far from some miracle panacea. In fact, I was somewhat concerned after this success case that people would be inspired to use intra-arrest lytics more liberally(inappropriately). Despite the fact that the majority of cardiac arrest etiology is probably either MI or PE, to my knowledge just blindly adding lytics to the CPR medication regimen have never been shown to be beneficial, even in fairly well-designed RCT’s. I agree for intra-arrest lytics to be worth a whirl, not only should you clearly have something to go on to strongly suspect MI or PE, but you also gotta have the right patient with the right set of circumstances. I view everything we do in the arrest patient as a temporizing measure with the real goal being to figure out what hell the etiology of the code was, and then figuring out how to reverse it! That’s why I think intra-arrest ultrasound is indispensable, and I think Echo is probably 80% of it. I can’t wait till our shop acquires beside TEE (game changer!)

        You don’t have to convince me of the benefits of ED ECMO- I’m sure it is a miracle in the right patient and I can’t wait till we get that here as well! (we are working on both). Having said that, if ECMO & Thrombolytic administration are truly mutually exclusive (due to inevitable exsanguination), would you concede that we may be looking at some specific circumstances where continuing with “Standard CPR” may actually trump “ECMO-CPR”; ie: the Lytics vs ECMO patient. For example, in this very case, if it was your patient at your place, you likely would have been contemplating Lytics vs. ECMO just as you did in your PE refractory V-FIb patient. You’re an ECMO guy so let’s say you decided to go with ECMO and so you withheld the lytics… it’s hard to say what the outcome might have been? I will say that the stars were aligned in our case… in the words of Thomas Scalea: “N=1… but it’s a pretty cool N!”

        I do have a few questions for you:

        Typically- how many mins into a code are you when you decide to pull the trigger on ED ECMO and roughly how long does it take you on average from start to Stage III and running?

        Also- wondering how often does the scenario happen where you have made the decision to initiate ED ECMO then decide to abort? (for whatever reason: unsuccessful, improvement in patient’s condition, etc)

        Thanks so much for your thoughts!

        -Sam

        • Sam, great thoughts and questions.

          1. ECMO and lytics aren’t mutually exclusive – just adds a huge level of difficulty and risk – I didn’t mean to imply an absolute contraindication in my last post. (see my response to Scott’s question here).

          2. ECPR vs. lytics. Well…I think the answer to that is similar to the question of whether you would prefer to take a STEMI to the cath lab or push lytics (in a non-arrest). If you have cath lab availability (and a cardiologist willing to take them), then that is better. If my cath lab is available, I’m doing ECPR and taking them to the lab on pump. 100% of the time. Cath lab down or not avail, intra-arrest lytics are an option. **in fact we are trying to set up a program here in San Diego where we would go to satellite hospitals for patients with post-arrest ROSC but cardiogenic shock….cannulate…and bring them back to our place. Some of those will most certainly have gotten lytics. And I would cannulate those – although might consider using TXA in those.

          3. Timing of ECPR? I put a 5FR art line (soon switching to micropuncture 4FR) and 9FR venous in the femorals immediately upon patient arrival, intra-arrest. Every time. We refer to that as ECPR Stage 1. I transduce the art line to do hemodynamic goal-directed resusc. If ROSC not achieved, I move to Stage 2 and dilate up. We used to wait until the point at which the pt would have been declared dead, but we now cannulate asap, but with a good-faith estimate that ACLS has failed. our average time from arrival to ‘on-pump’ is between 45 min and 1 hr 10 min. Jokingly, that is now referred to our D2B time – but not door to balloon, door-to-bellezzo (the folks out here like to bust my b***s).

          4. Termination of ECMO? Yep, it happens all the time. Examples: persistent asystole after going on pump; a patient who was cathed a week earlier and had diffuse disease (no focal lesion to be instrumented); family arrives and declares the pt a DNR due to terminal illness (that we were unaware of during the code.) We err on the side of initiating ECPR and then shut down if that’s the right thing to do. Since ECMO is temporizing (FDA approved for 6 hours max) we haven’t had problems with discussing withdrawal of care in the proper scenario.

          ~Joe

      • Scott pointing me to the rabbit hole!

        His question, though is binary. At my shop our cardiologists will take a pt on ECMO to the cath lab. period. Even if still in VF storm. Even with no STEMI on EKG. They are aggressive and I know…the world is changing and this practice will most certainly go the way of the dodo. So I wouldn’t be in a position to rescue a lysed patient unless our cath lab was down. And I will concede that ECMO doesn’t perfuse the portion of myocardium that is obstructed…but it is a wonderful way to perfuse the brain and remaining coronaries until the vessel can be opened…usually within in an hour. The additional huge benefit is the post arrest support. Almost every patient we see that gets put on pump has usually received around an hour of compressions (or 25% of endogenous forward flow to the brain and remaining coronaries) and they all have the “post cardiac arrest syndrome.” Most have EF’s that are single digits initially. We anticipate this. It is going to happen. and ECMO is a nice bridge to handle that.

        Now, to Scott’s point:

        what if our cath lab is down, an arrest gets ROSC after lytics, and then flags? max pressors and MAP dropping (again the post cardiac arrest myocardial dysfunction)? Indeed I would cannulate and put them on pump. Not ideal, but (I’ve said it a million times), “if death is you ONLY alternative….”

        So lytics are not an absolute contraindication to ECMO. I’ll give you that.

        Now what I would do is start Tranexamic Acid or Amicar (or aprotinin if you are old school!) just before cannulation.

    • Joe Bednarczyk says:

      Hi Joe – Two weekends ago we cannulated a patient with VA ecmo for refractory shock with acute saddle PE after failed lytics, also on full dose heparin. I was on the arterial side and it was quite bloody between dilations, but definitely doable. I am not sure we should consider lytics an absolute contraindication to ECMO, but certainly during ECPR this may be even more challenging.

      • Joe, I agree. My initial comments were meant to entice discussion. Lytics are not an absolute contraindication by any means. But if I had the choice I would cannulate and go to the cath lab and avoid the lytics. CTS will put pt’s on CPB after receiving lytics too, its just messier.

        Nice job on the arterial cannulation, which are always bloody.

  2. Ari Kestler says:

    Our cardiologists won’t touch these patients with a 10 foot pole. Seems lytics should be used more for presumed massive stemi with no ecmo capability or an interventionalist unwilling to cath. (Awaiting ebm flame war)

    • samghali says:

      Hi Ari,
      I also had a recent case that was presented as an M&M- 34 y.o. V-Fib arrest, not only witnessed- but furthermore witnessed right in front of medics (obviously with immediately CPR)- who Cards refused to take the lab. He had achieved and sustained ROSC prior to arrival in our ED. EKG showed somewhat bizarre/atypical ST Elevation, but either way he certainly deserved a trip to the lab. He went upstairs to the unit, coded a few hours later, and the code was ultimately called. Autopsy showed acute, extensive coronary occlusion. It’s unfortunate that their concern for cath lab mortality metrics takes precedence over saving lives. It’s pretty ballsy, but in these cases maybe we should be pushing lytics in the face of a cards refusal to take the patient. Who knows what the future holds for emergency physicians- from bedside TEE…to REBOA…to ECMO- maybe one day in the future we can just do the damn cath ourselves at the bedside!

  3. Lakshay says:

    Great case!
    We had a similar case about a year ago when I was just signing off my shift at 9AM.
    We got a 50y/M brought in with V fib witnesses LOC – 10 min back. He got good CPR for about 40-45 minutes with 12-15 shocks – epi – amio – lidocaine – Mg – he attained ROSC 5-6 times but we kept on losing him – somehow we got the EKG done and LUCAS helped us a lot.
    EKG was showing tombstones across his precordium. We also ruled out a tamponade and PE with intraarrest echo.
    We contemplated about lytics and bicarb – but none was given instead we involved catfiology after 30 minutes of code.
    They were kind of upset for continuing the resus for such a long time and wrote hypoxic ischemic encephalopathy on the chart, we still tried hard convincing cardilogy – pushed him to cathlab – 100% LAD block.

    And — next morning 9AM – in follow up – he was ready for extubation. GCS – 10T/15
    And cardiology regiatrar says to my boss – “you saved him”.

    Thanks
    Lakshay

  4. Great thought provoking wee! Reminded me of an interesting case series Steve Bernard (Alfred hospital Melbourne) and his team are collecting….refractory VF while on ECMO (ECMO CPR cohort for the CHEER trial)…..successfully treated “at the end of the needle” with a bolus dose Isoprenaline. Might be something in there…..

    For Steven Bernard’s talk see intensive care network podcast March 7th 2014.

  5. Many great comments here. And Sam I totally agree with the thought of us just doing the cath ourselves! There are a great deal of questions floating around this thread but I will focus on one of them. Is ECMO better than conventional resuscitation and if so at what point does ECMO become better? The extremes are obvious. Grandma comes in with a stubbed toe -> don’t put her on ECMO (Joe refrain yourself). Also, Grandma has rigor mortis–> don’t put her on ECMO (Joe, I know you’re still thinking about it). Neither of these cases benefit from ECMO. But how about we talk about the patient who hasn’t even arrested yet. Hello Cardiogenic Shock. These patients may actually benefit most from ECMO (reference Combs Crit Care Med 2008 Vol. 36, No. 5). Not conclusive data but worth a ponder. Ok, move on to post arrest. The data is sparse for the immediate cardiac arrest patient (<10 min of arrest time) but one study did attempt to answer your very question for all comers. The Taiwan group did case matching to try to compare apples to apples and showed benefit (reference Chen Lancet 2008). I will say our data also shows similar findings (now if I can only get this @#$% paper done). We have no randomized control study yet, but the SAVE-J group out of Japan may be the first to publish this level of evidence. Bernard's study will be fantastic but not an RCT. Until then, the question remains "To cannulate or not". The discussion about lytics is interesting but I think the better foe to immediate ECMO is LUCAS to cath lab without ROSC. My educated opinion is strongly in favor of ECMO but more data is definitely needed.
    Zack

    • very well said! now if we can get those evidence links to be edecmo study links instead we would really be scoring :)

    • SAMGHALI says:

      Joe & Zack,
      Thanks so much for your insights.
      Alright, alright.. I’ve now become sucked in to edecmo.org (I’ve got some cast catching up to do!)
      Zack, by the way- I will give it until 2020. I can see the headlines now… of course Scott will have that first ED Doc on for the interview: “Podcast 323- Resuscitationist-Performed Cardiac Cath” !

  6. Sounds like a great case and awesome job by the primary team. Although tPA worked well here, it is difficult to identify the patient that is going to breeze through the post-cardiac arrest state and those that are going to continue to have post-cardiac arrest myocardial dysfunction. Decompression of the LV will reduce myocardial oxygen consumption by decreasing LVEDP and give hopes to myocardial recovery, and ECLS can provide that. Also mechanical unloading of the LV can improve right ventricular function, and it has been shown in patients with VADs this result in less myocardial fibrosis and ventricular remodeling. Therefore the post-arrest benefits seem to favor ECLS.

    This isn’t to say it’s a “cure-all” as I’m sure you have seen the fatal hemorrhages, infectious complications, limb threatening arterial insufficiency and myriad of other complications. Without better data, I think, the chances of getting the patient through that critical 24 hours is higher in patients who go on pump than get peripheral tPA, understanding the logistics of ECCPR not be available at most ED’s in the US (it is pretty sweet that you guys are going to other shops and cannulating and bringing them over to you though!).

  7. Karl Brennan BSN RN CCRN MICP says:

    Scott just curious as to why prehospital folk were unable to get a 12 lead With the administration of lidocaine, bicarb etc it suggests a possibility of recovery from the VF with the defibs, for a short period. Should they have instituted ROSC (cooling) in the field ? Pt past history would have been great along with any medications. Otherwise fantastic job of resusitation. I know cath labs are all different as well as the cardiologists, my opinion would have been to take him to the lab after the administration of the lytic, It all works out in the end with the best interest for the patient in mind. Great case with a fantastic outcome!

    • Kim’s study (published in same issue as TTM Trial) argues against any benefit of prehospital cooling. NYC data will probably show the same.

Trackbacks

  1. […] we use thrombolytics in more cases of cardiac arrest? EMCrit discusses a case of prolonged arrest with VFib storm and the use of thrombolytics […]

Speak Your Mind (Along with your name, job, and affiliation)