1. (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)

2. 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

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

4. How will it work in our ED?

5. Activation
Timing
Patient
Exclusion criteria
Who to call

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

7. 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 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)

8. 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

9. How to activate
Call 555 and state eCPR activation

12. Assemble team
Who arrive
Who are needed

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

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

15. 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)

16. 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

17. 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

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

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

20. 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

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

22. History Attempts to gain further PMHx Actively seeks STOP criteria
Medical records
Family GP
Actively seeks STOP criteria

23. 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

24. 3. Cannulation Phase

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

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

27. 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

28. 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

29. On ECMO
Possible early defibrillation
Transfer to cath lab for PCA

30. 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