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

Can be performed in-hospital, or an OHCA. What is it? eCPR (extracorporeal CPR)/ ED-ECMO (Extracorporeal Membrane Oxygenation) is the initiation of bypass during the resuscitation of an arresting patient

Configurations VV ECMO- pure respiratory support: femoral-femoral, jugular-femoral, dual lumen VA- Cardiopulmonary support: femoral-femoral, central

How will it work in our ED?

Activation Timing Patient Exclusion criteria Who to call

Timing Monday to Friday 8-5pm 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 > 10min without BLS > 60min since collapse > 70yrs old Known organ failure or malignancy No realistic prospect of reversal

How to activate Call 555 and state eCPR 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

Precannulation Airway RN Airway TOE Drugs RN LUCAS Defib Access RN 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 EtCO2 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 Actively seeks STOP criteria Medical records Family GP Actively seeks STOP criteria

2. Pre-Cannulation Phase Arrival Standard ALS with LUCAS in place Airway Secure EtCO2 IV access and ABG Expose groin and shave Contact Cath lab 5-10 mins

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

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

Cannulation Phase Airway Drugs RN LUCAS TOE U/S C1 C2 ECPR Trolley Defib LUCAS TOE U/S C1 C2 ECPR Trolley ECMO RN TEAM LEADER Lead RN ECMO

Steps to Cannulation phase Prep & Drape groins Place guide wires in femoral artery and vein Confirm wire placement on TOE Administer 5000u Heparin Place venous cannula & clamp Place arterial cannula & clamp Cut ECMO circuit Attach circuit to cannulas without bubbles Unclamp & increase ECMO flows Secure hardware

On ECMO Possible early defibrillation Transfer to cath lab for PCA

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