Cite this post as:
Scott Weingart, MD FCCM. EMCrit Wee – A Case to Threaten Current ECMO Evidence from Sam Ghali. EMCrit Blog. Published on August 15, 2014. Accessed on August 18th 2022. Available at [https://emcrit.org/emcrit/prolonged-cpr-case/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: August 15, 2014
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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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… Read more »
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?
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… Read more »
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… Read more »
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… Read more »
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.
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)
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… Read more »
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… Read more »
a case like that changes the entire complexion of an institutions approach to arrest
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.
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… Read more »
very well said! now if we can get those evidence links to be edecmo study links instead we would really be scoring 🙂
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” !
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… Read more »
yep!
Exactly!
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… Read more »
Kim’s study (published in same issue as TTM Trial) argues against any benefit of prehospital cooling. NYC data will probably show the same.