Bypass the OR: ECMO in the ED

We just finished a two-part series with one of our former Chief Residents, Dr. Zachary Shinar. Zach has been working in San Diego at Sharp Memorial Hospital and more recently at UC San Diego. What he has been up to down there is nothing short of incredible.

Dr. Zach Shinar: If you can put in a central line or a dialysis catheter, you can place a patient on ECMO

We just finished a two-part series with one of our former Chief Residents, Dr. Zachary Shinar. Zach has been working in San Diego at Sharp Memorial Hospital and more recently at UC San Diego. What he has been up to down there is nothing short of incredible.

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At one of our recent grand rounds at USC, Zach presented a case in the old school style – by having the patient there in person. The patient was a somewhat portly middle-aged gentleman named Ralph. He had taken the train up from San Diego to join us. Having a patient at rounds was a real treat and he was very lively about his story. He was fascinated at the responses of all of the doctors. They were equally fascinated by him.

One day last year, Ralph was having intermittent jaw and chest pains. He was en route to hospital with paramedics when he suddenly went into full arrest. In total, he was without spontaneous circulation for just over an hour – 61 minutes to be precise.

When he arrived at Sharp Memorial, CPR was in progress. Zach and emergency medicine colleague Dr. Joe Bellezzo, fresh out of a departmental meeting on emergency extracorporeal membrane oxygenation (ECMO), placed the large femoral catheters necessary and initiated cardiopulmonary bypass.

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“You don’t have time to wait for the whole perfusion team,” Zach told us. “This is emergency ECMO by emergency doctors and nurses.” In his estimation, the actual nuts and bolts of the procedure are not that far-fetched for any ED to perform, as long as the necessary back-up services to take patients to definitive therapy are close at hand. “If you can put in a central line or a dialysis catheter, you can place a patient on ECMO.”

The first step is to insert central lines into both the femoral artery and vein using the regular Seldinger technique. These are then exchanged via guidewire for progressively larger vessel dilators so that the very large bore ECMO catheters can be inserted. Once the catheters are ready, they are connected to the ECMO machine. At Sharp, nurses with special expertise are available around the clock to run the machine for the first hour until a perfusionist can take over.

After ECMO was initiated, Ralph was taken straight to the catheterization suite for a presumed coronary occlusive event. This revealed a 100% left anterior descending lesion that was quickly stented. He was extubated that same day and he walked out of the hospital a few days later – completely and utterly neurologically intact. Absolutely amazing. A testament to good quality CPR to be sure, but also to the application of a technology widely utilized in surgery and intensive care but rarely considered an option in the ED.

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The program at Sharp is one of only a select few in the world that have protocols for ED ECMO. It may be the first program in the US run out of an ED. “The key to the program’s success is patient selection,” Zach explained. First, there must be a reasonable expectation of neurologic recovery. “If there was no or little delay in CPR after arrest and continuous high quality CPR is in progress, one hour may seem like forever, but it’s not really outside the window if you look at the world’s literature for emergency ECMO.” Secondly, and equally important, if you don’t have a destination for the patient to correct a reversible problem, either the operating room, the interventional suite or hemodialysis, there really isn’t an indication for ECMO.

In the last 18 months, the ED at Sharp has placed 9 patients on ECMO – 4 of these have walked out of the hospital neurologically intact. These are patients in whom all other resuscitative efforts and ACLS measures have failed. In other patients the process was initiated by insertion of catheters but then abandoned when no clear path to definitive care was identified.

The ethical dimensions of all of this are enormous. In fact, we worried a little bit about running the interview on EM:RAP because we felt that many in our audience would think this is a bit unrealistic and raises the bar too high. But upon reflection, this is precisely where our specialty is heading: aggressive reanimation of those patients that still have a meaningful quality of life ahead of them. How this technology is applied is going to be controversial, but if we don’t forge the way ourselves, others may take the initiative from us.

In our next piece, we will discuss another cutting edge technology in the ED with Zach: the LVAD (Left Ventricular Assist Device).

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SHARP PROTOCOL FOR ED ECMO

Inclusion Criteria

• Persistent cardiopulmonary arrest despite traditional resuscitative efforts
• Shock (SBP<70 mmHg) refractory to standard therapies

Exclusion Criteria

• Initial rhythm asystole
• Chest compresions not initiated within 10 min of arrest (either bystander or EMS personnel)
• Estimated EMS transport time > 10 min
• Total arrest time > 60 min
• Suspicion of shock due to sepsis or hemorrhage
• Pre-existing sever neurological disease prior to arrest (including traumatic brain injury, stroke, or sever dementia)

Dr. Swadron is currently Vice-Chair for Education in the Department of Emergency Medicine at the Los Angeles County/USC Medical Center in Los Angeles. He is an Associate Professor of Clinical Emergency Medicine at the Keck School of Medicine of the University of Southern California. EM:RAP (Emergency Medicine: Reviews and Perspectives) is a monthly audio program that can be found at www.EMRAP.org)