Grand Rounds Recap 11.15.17

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ED CRITICAL CARE: Developing an Emergency Department ECPR Program with DR. KYLE GUNNERSON

Why ED-based ECMO? 

  • In general, Out-of-Hospital Cardiac Arrest (OHCA) outcomes have not significantly improved despite an increase in bystander CPR; how do we improve those outcomes?
  • For patients with refractory cardiac arrest or profound cardiogenic shock, ED-based ECMO (i.e., ECPR) can be a useful tool.
  • A series of trials over last 15 years has shown increasing ECPR survival rate up to ~60%, much greater than the standard OHCA survival rates of 5-10%.
  • ECMO restores or augments cerebral, coronary or other organ circulation but must be a bridge to a certain procedure or intervention (e.g., cath, disease state recovery, tra nsplant).
  • The primary goal is rapid return of spontaneous circulation with a secondary goal of minimizing ischemic brain injury.
  • The process starts with goal-directed CPR followed by ED-directed V-A ECMO.

How do you optimize your CPR quality?

  • Monitor physiologic parameters during CPR, such as coronary perfusion pressure (goal >25 mmHg), arterial relaxation pressure (proportional to diastolic blood pressure; goal >35 mmHg), EtCO2 (goal >20 mmHg) and even cerebral oximetry.
  • ROSC dependent upon increasing coronary perfusion pressure, which can be affected by aortic relaxation pressure and intrathoracic pressure.
  • Increase aortic relaxation pressure: attempt to optimize coronary perfusion pressure by increasing cardiac output (optimize chest compression rate, depth; use external compression device such as a LUCAS) or by increasing arterial resistance via vasopressors such as epi +/- vasopressin.
  • Decrease intrathoracic pressure (use an impedance threshold device such as Res-Q Pod).

What kind of patient is a good ED ECMO/ECPR candidate?

  • Case selection is very important, as is time to initiation
  • Inclusion criteria includes certain age parameters, a witnessed arrest (or at least recurrent VT/VF arrest), a suspected reversible cause, and < 60 minutes from time of arrest to ECMO flow.
  • Exclusion criteria includes contraindication to anticoagulation, estimated BMI > 40, severe or life-limiting comorbidities or if the physician determines further care is futile.

Who is involved? How does the training happen?

  • The team is specifically trained to safely initiate all aspects of ECPR in the desired timeframe. This classically involves CT surgery, a perfusionist and an ECMO specialist. 
  • As time to initiation of ECMO is important, it makes sense for ED physicians to be involved in this (in some countries, this is even done in the field!).
  • Two day training course for ED physicians and nurses involving didactics and hands-on training involving anything from didactics to getting access to running the circuit.
  • High-fidelity mannequin simulation to practice ultrasound-based access with cannulation tools chosen specifically for ease of use and safety.
  • Checklist for physicians and nurses to ensure safety and compliance.
  • Training both in the simulation lab and in the ED; goal-directed CPR on-going during training. 

Other Tips on Initiation of ECMO in the ED

  • Everyone gets a right radial a-line for blood gasses (as an estimate of coronary and cerebral oxygenation and perfusion)
  • Everyone needs some kind of distal limb perfusion cannula (SFA or PTA); this can be placed by ED team or CT surgery.
  • Use a blender to dial down O2 levels to avoid supratherapeutic oxygen levels and potential free radial damage.
  • CT of the head, abdomen and pelvis are performed within the first 24 hours to look for other concomitant problems
  • Targeted temperature management is performed and cvEEG is initiated. 
  • Emergent cath for STEMI patients (especially VF/VT patients); consider early cardiac cath for NSTEMI patients. 
  • Must also train team on management of circuit and troubleshooting things such as bleeding and clotting; this is often accomplished by specially-trained ED nurses.
  • Teamwork is the most important key for success -- everyone must be on board.

ED-based ICU: A Paradigm Shift or Oxymoron?

Background

  • Majority of admissions come through the ED; ICU admissions have doubled in the last decade.
  • 1/3 of all ICU admissions spend > 6 hours in the ED.
  • The effectiveness of care for acute injuries and illnesses is very time-sensitive
  • Who takes primary responsibility for ICU patients boarding in the ED?
  • Having patients remain boarding in the ED is not ideal for their physiology or disease processes and likely increases their mortality.
  • ED visits continue to increase as do ICU admissions; lengths of stay in the ED are not improving either.
  • This puts the ED in the unique position to develop an ED-based ICU care model.

Plan of Action

  • Instead of having a traditional "silo" model of critical care, they proposed an integrated model of emergency critical care involving multidisciplinary ICU level care
  • Goal: "Create the infrastructure and system necessary to provide time-sensitive diagnosis, treatment and monitoring of critically ill patients."
  • Used LEAN model to create multidisciplinary team that involved everything from physicians and residents to nurses, research staff and even environmental services.
  • Toured other systems to see physical plans, equipment, structure, etc. 
  • Created staffing model with attendings as well as a resident/fellow and a 2:1 staffing model for nurses.
  • Worked with architects to create physical plant; did a full-scale mock up of a room that led to significant design changes. 

The Clinical Care

  • Attendings were both EM/CC-trained and non-fellowship trained; FCCS course held for those who were not fellowship-trained with ongoing, monthly continuing education.
  • ED nurses went through rigorous critical critical care training as well.
  • Medical students, residents and fellows rotate through the service.
  • CC Advisory group created order sets to standardize treatment for common presentations (e.g., sepsis, cardiac arrest).
  • Initial workup performed by ED team; EC3 is then consulted and the patient is transferred to the EC3 area.
  • EC3 is a closed unit with an average LOS of 11-12 hours; after about 6 hours, the upstairs ICU fellow is contacted and there is a discussion about potential disposition to a specific ICU.

Results To Date

  • EC3 open since February 2015; have seen over 6500 patients to date, during which time the main ED has seen a 5% annual increase in volume as well as an 11% increase in admissions and a 32% increase in boarding times.
  • Unit averages approximately 7 patients each day.
  • After care in EC3, they have been able to send 28% of these patients to the floor instead of the ICU, allowing for a 17% reduction in ICU admissions and saving >1700 ICU bed days each year.
  • Overall, 58% of the patients from EC3 go to the floor, while 31% go on to be admitted to the ICU. 
  • Interestingly, 9% of patients are discharged straight from EC3.  
  • By increasing the number of ICU beds available, the institution has seen more ICU transfers from outside facilities. 

Ongoing Projects & Research

  • Three NIH funded research projects; recently awarded NIH K12 Career Development in Emergency Critical Care.
  • Established Comprehensive Critical Care Science Center with a goal to transform critical care medicine.
  • Involving strategic industry partnerships.
  • Working on continuing to evolve clinical pathways and protocols. 

AIR CARE GRAND ROUNDS with drs hinckley, powell, renne and dang & bob Francis and jennifer Lakeberg

Air Medical Resource Management

  • Goal of Crew Resource Management (CRM) is to enhance teamwork and communication to enhance safety
  • In 1979, a NASA-founded study looked at many air accidents and found that human error and poor communication were key causes. CRM was developed to include team building, situational awareness, stress management and decision making strategies
  • Air Medical Resource Management (AMRM) is a method of making optimum use of the capability of the individuals and the systems in an aircraft to achieve the safest and most efficient completion of a flight.
  • Leadership styles (relationship-oriented instead of task-oriented) and good attitudes lead to better teamwork and communication and thus safer flights.
  • In 8 of 10 incidents, someone, somewhere, had some piece of information which could have prevented the incident from happening but failed to share it. You can be assertive--stand up for what you think is right--while still being respectful.
  • Use a five-step process to communicate. One, lead with their name to get their attention. Two, state your concern or emotion (e.g., "I'm concerned about..."). Then, state the problem and propose a solution. Finally, ask their opinion (e.g., "What do you think?"). 
  • In general, the "most conservative" rule applies: the crew must respond conservatively to any ambiguity to that most options and alternatives remain available. 
  • Three methods of communication: verbal, visual or vocal. In a helicopter, some of these methods are available at different times; sometimes you have problems with communication due to the environment or difficulties with sending or receiving the message (e.g., your microphone is not working or the pilot is talking to the tower).
  • Feedback and debriefing is important. It reduces uncertainty, solves problems, and builds trust. Talk to your team after every flight and debrief!
  • To improve situational awareness, we use checklists and employ the concept of sterile cockpit on take off and landing. 

Simulation Session

The patient is a young male with unknown PMH for whom AirCare is called after a motorcycle accident. The patient was the unhelmeted driver of a motorcycle which hit a guardrail. He is unconscious on scene and placed in the back of an ambulance with EMS. Prior to AirCare arrival, the patient was immobilized, IV access was established and he is receiving oxygen via NRB.

Upon AirCare arrival on scene, the patient's initial vital signs are notable for a BP of 99/50, a HR of 123 and a RR of 8. He is satting 93% on the NRB. His primary exam is notable for a young male with a GCS of 7 (1-2-4) who is groaning and not protecting his airway due to low GCS but with initially clear breath sounds bilaterally. He has blood in his airway and a left chest wall contusion. His exam is otherwise notable for an unstable pelvis and a lower extremity open fracture with absent left pedal pulses. A fingerstick glucose performed by EMS is normal.

Due to his hypotension and physical exam findings, he is given 1U of PRBC and 1U of FFP on scene and a T Pod is placed. While this is being done, the patient begins to vomit. As the team prepares to intubate, they also draw up push-dose epinephrine in anticipation of post-intubation hemodynamic collapse. Half-dose ketamine and succinylcholine are used for induction, and the patient is successfully intubated on the first attempt without any significant perturbations of his hemodynamics. He is packaged and moved to the helicopter. 

In flight, the patient becomes increasingly hypoxic and difficult to ventilate. He becomes progressively hypotensive as well. Repeat physical exam reveals decreased breath sounds on the left, prompting a needle decompression and finger thoracostomy with improvement in his oxygenation and hemodynamics. Due to his low GCS and TBI, he is given 3% hypertonic saline as well as TXA for presumed hemorrhagic shock. The patient is transported to a Level 1 Trauma Center for definitive management.