e CPR EDECMO Dr Kevin Maruno Emergency Dept

e. CPR/ ED-ECMO Dr Kevin Maruno Emergency Dept St Vincent’s Hospital (with thanks Dr Sean Scott for slides)

What is it? e. CPR (extracorporeal CPR)/ ED-ECMO (Extracorporeal Membrane Oxygenation) is the initiation of bypass during the resuscitation of an arresting patient

Configurations

How will it work in our ED?

Activation • Timing • Patient • Exclusion criteria

Timing • Monday to Friday 8 -5 pm • Can it be done out of these times in extraordinary circumstances? ?

Patient • The cardiac arrest is likely to be of primary cardiac or respiratory cause • The cardiac arrest was witnessed by a bystander or paramedic • Chest compressions were commenced within 10 minutes • The cardiac arrest duration (collapse to arrival at ED) has been < 60 minutes • The patient is aged between 16 -70 years • There are no major co-morbidities that would preclude return to independent living • If non cardiac, the cause is likely reversible (eg hypothermia, overdose)

Exclusion- STOP criteria • • Unwitnessed arrest Asystole as initial rhythm > 10 min without BLS > 60 min since collapse > 70 yrs old Known organ failure or malignancy No realistic prospect of reversal

How to activate • Call 555 and state e. CPR activation

Assemble team Who arrive Who are needed

Team Roles Team leader Airway doctor Circulation/ Procedure doctor RNs: team leader, airway nurse, defibrillator/drug nurse • Gopher • •

TOE Airway RN LUCAS Precannulation Defib Drugs RN Access Procedure RN Ambo 1 U/S TEAM LEADER Lead RN

Team Leader • All communication and decision making must go through the team leader • Makes ECPR call to switch • Allocates medical team roles • Ensures all staff apply PPE and role sticker • Accepts the hand-over from the paramedics • Ensures QUALITY CPR • Ensures LUCAS properly applied • Determines eligibility for ECPR (delegate)

Nurse Team Leader • Active noise reduction and workspace clearing • • • Allocates nursing team roles Ensure all staff apply PPE and role sticker Ensures quality CPR Time keeper Commences and continues documentation

Airway Doctor • • Ensures airway patent Intubates if required Attaches Et. CO 2 Hand ventilates with bag/ valve/ mask with 100% oxygen at 8 -bpm on recoil of the LUCAS

Airway Nurse • Assists Airway Doctor if intubation required • Assists Drugs & Defib when airway secure • Leaves Resus bay when tasks complete

Circulation Nurse • Attaches defib pads to hospital defib • Pauses LUCAS for rhythm checks • Administers shocks & drugs as per ALS algorithm

Circulation Doctor Ensures adequate IV access If no IV inserts humeral IO ABG for reversible causes Places radial Arterial Line (during cannulation phase) • Leaves Resus bay when tasks complete • •

Procedure Nurse • Ensures LUCAS properly positioned • Plugs in LUCAS • Removes and troubleshoots LUCAS if malfunctioning • Exposes & shaves groins • Leaves Resus bay when tasks complete

History • Attempts to gain further PMHx – Medical records – Family – GP • Actively seeks STOP criteria

2. Pre-Cannulation Phase • • Arrival Standard ALS with LUCAS in place Airway Secure Et. CO 2 IV access and ABG Expose groin and shave Contact Cath lab

3. Cannulation Phase

Cannulation phase • • • Commences at skin prep LUCAS continues, CEASE defibrillation Continue drugs as per ALS Continue to seek reversible causes Cannulation begins

TOE Airway RN LUCAS Precannulation Defib Drugs RN Access Procedure RN U/S TEAM LEADER Lead RN

Cannulation Phase TOE Airway Drugs RN Defib LUCAS U/S C 1 C 2 ECPR Trolley ECMO RN TEAM LEADER Lead RN

Steps to Cannulation phase 1. Prep & Drape groins 2. Place guide wires in femoral artery and vein 3. Confirm wire placement on TOE 4. Administer 5000 u Heparin 5. Place venous cannula & clamp 6. Place arterial cannula & clamp 7. Cut ECMO circuit 8. Attach circuit to cannulas without bubbles 9. Unclamp & increase ECMO flows 10. Secure hardware

On ECMO • Possible early defibrillation • Transfer to cath lab for PCA

In summary: ED Team leader • 2 responsibilities: 1. ALS- good CPR, defib and drugs, monitor ventilation, seek and treat reversible causes 2. Good team dynamics- leadership, effective closed-loop communication, role clarity, anticipate and plan, allocate attention wisely