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Notes: A Stepwise Guidebook on Signing Vermont Emergency Examination Form Mh 11 Online

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The Definite Guide to Vermont Emergency Examination Form Mh 11

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Check How to Enter the Vermont Emergency Examination Form Mh 11

morning everyone this morning we were.inaugurating our remote band rounds we.are Yahner this morning to have great.fellow like dr. michael hart is finished.his medical school rushing their users.and went to university of minnesota.Seneca County Medical Center importance.to training and we're really proud to.have Mike Eliza fellow with distinguish.himself with his interest in heart.failure if we all respect his knowledge.and this morning it's going to address.this on ECMO CPR thank you for that.introduction and good morning I guess.there are pros and cons to this new.webinar formats the pro mainly being.that you can watch this from home in.your bathrobe if you want but I guess.the con is you can't boo in my face if.you hear something you don't like but.the show must go on and so let's jump to.this morning's objectives so after today.hopefully we can understand the basics.of VA ECMO including its history of use.in adults we want to review the human.dynamics of cardiogenic shock and VA.ECMO identify the common objectives.indications and contraindications to the.ECMO use and EC PR and then highlight MH.eyes approach to e C PR management's and.experience and its use so to bring.things a little bit closer to home we'll.start with a case we have a 50 year old.female Taekwondo instructor for whom 911.was called at the end of class as she.was complaining of some dizziness and.lightheadedness maybe some chest.discomfort to a bystander and actually.suffered a brief loss of consciousness.on EMS arrival she was confused and.diaphoretic and unfortunately at this.point we don't know anything about her.past medical history or medications.objectively she was vitally stable at.this time and had a normal.cardiovascular and.long exam though she was diaphoretic and.clammy and again kind of confused and.unable to answer questions appropriately.initial EMS rhythm strip showed what.appears to be atrial fibrillation with.significant Q wave development.throughout the inner lateral leads and.concomitant st-elevation with reciprocal.ST depression inferiorly and thus with.appropriate concern for acute MI the.patient received aspirin and.nitroglycerin and was transported.emergently to MH I unfortunately enroute.she became more obtunded and bradycardic.and ultimately lost pulses with.initiation of manual CPR as the rig.pulled into the ambulance Bay in the.emergency department appropriate H a.ACLs cares ensued including intubation.and mechanical CPR with Lucas device.multiple medications as you can see.listed here defibrillation attempts for.ventricular fibrillation and now.evidence on the monitor and despite all.of these efforts were unable to achieve.roske and she was transported emergently.to the cath lab with no perfusing rhythm.and no pulse so where do you go from.here when your ACLs algorithm kind of.falls short or has no more answers for.you well to understand the answer and.why it's different now than it was 50 to.60 plus years ago you really have to go.back and look at the advent of cardiac.surgery and its growth dependence on the.heart-lung machine development in the.40s and 50s the growth was slow for a.number of reasons I'll get to in a.moment but in part again because only a.few surgeries could really be performed.in the absence of cardiopulmonary bypass.contributing to that was the poor.results in the 1950s with the review.being released by dr. Lula high and the.literature of all cardiac surgeries.open-heart surgeries.reported in the literature at that time.between 1951 and 1955 with 18 different.surgeries at six different centers with.17 deaths and these are just the ones.that we know about and so as I alluded.to a couple of the reasons for failure.while there are multiple.with really limited collaboration at.that time a complex cardiac surgery.certainly was still in its infancy and.you know that was at least an product of.multiple perioperative issues this.including Airness preoperative diagnosis.of frequent intraoperative air embolism.and just rampant post-operative bleeding.now furthermore there were no.institutional review boards until the.1970s only the sickest patients were.referred again there was no reliable.cardiopulmonary bypass apparatus so as.you can imagine this kind of led to a.race to develop such a machine with at.least five different groups likely more.working on this objective at the same.time pictured here on your left is the.Dowager old General Motors research pump.which was said to resemble a 12 cylinder.engine and then on the right is your.Cowen Mustard heart-lung machine which.actually used a pair of rhesus monkey.lungs as the oxygenator now not to be.left out of the race Minnesota soon.threw its hat into the ring pictured.here is the affirmation dr. Lola high.who developed this cross circulation.technique which actually uses the.patient's parents either mother or.father as the oxygenator during the.operation and after a successful VSD.closure dr. John Kirkland from Mayo.Clinic was quoted as saying I was.terribly envious and yet I was terribly.admiring at the same moment and that.admiration increased when a short time.later a few of my colleagues and I.visited Minneapolis and observed a.succession of open heart operations now.not to be outdone by his neighbors from.the north dr. Kirkland would set out to.develop his own heart-lung machine.really building off the work done by.this dr. John Gibbon who I want to spend.a few moments on now doctor given.graduated from Jefferson Medical College.in 1927 and worked as a research.assistant at MGH in 1930 studying.pulmonary embolus and pulmonary.embolectomy during his time there he was.asked to follow a patient that was.status post cholecystectomy with a.suspected pea.and plan for a pulmonary embolectomy if.she had reached extremists again because.the surgical risk was so high and so as.part of his care he monitored vitals.every 15 minutes overnight and slowly.noted increasing venous distention and.cyanosis and ultimately dangerous.decrement and blood pressure at which.point he alerted the surgery team now.unfortunately this patient did not.survive after going to the or but it.really did spur doctor given to say if.we could just remove the venous blood.expose it to oxygen and pull out the.carbon dioxide and put it back into the.arterial system we could hemodynamically.support these patients you know while.they undergo whatever operation they.need and as a result he would.essentially dedicate his life to that.venture pictured here is his Gibbon IBM.heart-lung machine which was made of.stainless steel and weighed over 2,000.pounds the oxygenator in this case was.comprised of six enclosed steel screens.with blood flowing down the sides which.would expose that blood to oxygen and.affords about seven meters squared of.surface area for gas exchange as opposed.to the 70 or 80 meter squared that we.have in our native lungs but again.achieves a hundred percent oxygen.saturation and flows up to five liters.per minute and thus in May of 1953 he.was able to use this creo pulmonary.bypass apparatus to perform a asd.closure on an 18 year old female with.right-sided heart failure.now pictured here the notes actually.taken reportedly by his wife who.witnessed the procedure and the.complications depend on where you look.but included black blood foaming and.oozing from the circuit some of the.oxygenator screens were completely.devoid of blood altogether the pressure.in the circuit was going up and down.precipitously and there was just a.massive amount of blood loss.despite this the procedure technically.was a success and dr. Gibbon would go on.to say after we finally got ready it was.ridiculously easy.so how do you get from Korea pulmonary.bypass to the ECMO well you really have.to fast-forward 20 plus years to the.work being done by dr. Donald Hill and.his successful cannulation in support of.this 24 year old male who suffered a.tramatic thoracic aortic injury with.resultant RDS the results of which would.be published in the New England Journal.of Medicine in 1972 now working at the.same time on extracorporeal circulation.and support as dr. Bartlett who would.soon become a major figure in ECMO.history his contribution specifically.revolved around the development of a.sustainable membrane oxygenator which.would allow for prolonged runs of.extracorporeal circulation support he.would ultimately return to the.University of Michigan in 1980 and.helped form the extracorporeal life.source organization in 1989 but perhaps.what he's best known for is the case of.orphaned Esperanza which was the first.successful newborn supported on ECMO for.about a week in the context of a RDS now.pictured here is Esperanza at 21 years.of age survived and did quite well and.the membrane oxygenator that dr..Bartlett helped develop would go on to.help support hundreds of newborns in the.setting of respiratory failure after.which he was aptly dubbed The Godfather.of ECMO as you can imagine multiple.iterations I would ensue on dr..Bartlet's circuit oxygenator as well as.a number of the other machines I've.already listed and as a result research.started to pour out particularly in the.setting and at least initially of acute.respiratory failure RDS on the efficacy.of ECMO and affecting survival rates.when compared to standard cares alone.and that research course was really.serpents and marred by conflicting.results on that efficacy though.ultimately culminated in the more.contemporary trials seizure in yo leo.which were published in 2009 and 2014.respectively which in conjunction with.the h1 and.one flu epidemic in 2008 and 2009 I.really led to an explosion and ECMO use.for respiratory failure meanwhile.cardiopulmonary resuscitation a.utilization of ECMO was also starting to.grow.certainly in part thanks to both of.these highly cited or frequently cited.rather propensity matched observational.trials.the first being prospective in the.latter being retrospective but both.showing a significant decrease in risk.of mortality with neurologically.functional favorable survival at 30 days.in one year for the first trial I which.was set in Taiwan and the latter trial.is well set in Seoul Korea both of these.trials again while being observational.which is certainly a limitation the data.that we have thus far on Vietnamese is.you know at least allowed or contributed.to the significant increase in ECMO runs.for adults with about a twelve hundred.percent increase in the last decade and.why has ECMO grown to become so popular.beyond the fact that it's kind of a new.technology and we like new things well.first and foremost ECMO provides full by.ventricular circulatory support as well.as oxygen at oxygen ation support which.is unique to ECMO furthermore is a great.modality for correction of acid-base.abnormalities as well as rapid rewarming.in the context of severe hypothermia and.furthermore the site of cannulation is.becoming more and more ubiquitous so you.see reports of cannulation and the.emergency departments in the O R and the.cath lab and sometimes even in the.Louvre.what is that mom you know let's get down.to brass tacks ECMO is a circuit and it.has four components which we'll go.through but you know akin to what dr..Gibbon was trying to describe.essentially pulls blood out of the.venous system passes it through a.permeable filamentous membrane which.adds oxygen and removes carbon dioxide.and then pumps it back into the body for.support excuse me in the four components.I was mentioning include the pump the.oxygenator the cannula and the tubing so.let's start with the pump well.historically we use these roller pumps.the ECMO circuits of today now have.shifted to a centrifugal pump which.helps mitigate some of the wear and tear.that you see with the tubing with the.roller pumps as well as a you know some.degree of traumatic hemolysis that was.more prevalent in the roller pumps than.the centrifugal pumps the oxygen air is.perhaps the most important component of.the ECMO circuit and traditionally was.made of silicone rubber which acted as.an okay medium for gas exchange but has.since been replaced by hollow poly.methyl pentene fibers which are stacked.on each other and really act as.excellent modems for gas exchange and.also have really low resistance to blood.flow which as you can imagine also helps.mitigate traumatic hemolysis but also.staves off this plasma leak phenomenon.that you would see with earlier.oxygenators to control the amount of.oxygenation or saturation that is of the.blood you're really controlling the.blood flow through the circuit or.adjusting the fraction of inspired of.oxygen oxygen to control the amount of.carbon dioxide and rate at which that.carbon dioxide is extracted from the.blood you're adjusting the sweep speed.which is essentially that speed of.counter current gas flow that you see.kind of running through the oxygenator.here.quickly attached to the oxygenator is a.heater cooler unit which again in the.setting of extreme hypothermia can allow.for rapid rewarming or in the context of.cardiac arrest which we'll talk a little.bit more specifically about later can be.used for targeted temperature management.the cannula are listed here on the left.typically are 21 to 25 French in size.for inflow and 15 to 21 French size for.outflow cannula and that nomenclature.inflow and outflow cannula really speak.to the circuit itself ok the circuit is.the boss so inflow cannula is cannula.flowing into the circuit and outflow.cannula is flowing out of the circuit to.the body the tubing here is about 3/8 to.1/2 inch in diameter and covalently.bonded to heparin which effectively.decreases the inflammatory process and.complement activation that we can see in.these patients which also helps stave.off from BOCES.pictured here.different cannulation strategies or.modalities really these falling into two.major buckets peripheral and central.peripheral is listed here on the left.and is probably what we see most often.upstairs in the ICU but that typically.includes by femoral cannulation in the.center you see an example of central.cannulation which is defined as having a.least one cannula entering or exiting.the thoracic cavity and advantage of.this is you can essentially supply.forward flow instead of retrograde flow.up the aorta which you see here in the.peripheral cannulation configuration so.that's hemodynamically favourable and.we'll get to why here in a moment and.also as you can imagine you're.essentially eliminating the risk of.peripheral vascular damage.albe 'it's at the cost of increased risk.of sternal dehiscence and infection and.bleeding the figure on the right here is.called sport mode which is also pictured.here but in all reality it has been a.great addition to the configuration.options available to us particularly in.those patients that require prolonged.runs of ECMO you know these patients can.be on ECMO for weeks and are combating.critical illness myopathy and by.allowing them to mobilize you know we're.decreasing that risk and the associated.comorbidities or morbidity rather that.is associated with such I particularly.like this picture on this left hand side.this gentleman looks like he's.determined to outlive us all here a.couple different you know schemas or.strategies for cannulation the bottom.two being you know more of our.traditional VA ECMO but this is also a.scenario in which nomenclature and.understanding that nomenclature is.important so when you're talking about.VV a or Vav or some permutation of.either once you hit the a once you've.reached that a reading left to rights as.we should you're talking about outflow.cannula so in the example up here in the.top left you have VV a so you have two.venous inflow cannulas and a.single arterial outflow cannula Vav.which is a helpful configuration when.you're dealing with something called.Harlequin syndrome which we'll get to.here in a moment has a single venous.inflow Cana and then two outflow.cannulas so you're really providing.oxygenated blood to both the arterial.system and the venous system and.depending on your clinical scenario.particularly in this context if the.cardiac function improves or recovers.prior to the lungs recovering Vav can be.a good option for you.okay so we've gone through the basics of.VA ECMO and we've talked about its.history why don't we review the human.AMEX of cardiogenic shock and VA ECMO so.cardiogenic shock as we all know is a.state of persistent hypotension with.inadequate response to volume.replacements in clinical features of end.organ hypoperfusion so this can be.altered mental status or oliguria.typically giving you this cold and wet.kind of physiologic picture.hemodynamically this can be corroborated.by a systolic blood pressure less than.90 cardiac index less than two two and a.wedge pressure greater than twenty four.in the presence or absence of balloon.pump usually with vasopressors or.inotropes on board now this is a semi.recently released schema which has also.been endorsed by ACC in Skye which.really breaks cardiogenic shock in two.different clinical stages in an effort.to provide some sort of template for.when you should really be implementing.certain therapies whether that be.vasopressors or inotropes or devices and.unfortunately unlike the food pyramids.that we grew up with it does not get.sweeter as you go to the top.specifically there has been a review in.the literature and analyzing the utility.of this schema and real-world patients.showing an increase in mortality as you.kind of climb that ladder towards.extremity rates getting up to 67%.now let me pause for a moment because I.would bring shame to my heart failure.attendings if I didn't speak for a few.minutes on pressure volume loops and the.importance of understanding them when.caring for these critically ill patients.so if you don't look at these every day.or I've never seen one before I bear.with me this is your PV loop at steady.states and each pressure volume loop.really represents a single cardiac cycle.you have pressure here on the y-axis and.volume on the x axis and we'll start.here at point one which is end.isovolumic relaxation now moving from.point one to point two during diastole.the mitral valve opens and the left.ventricle fills with blood until it is.maximally filled at point two what.follows is iso voluma contraction from.point 2 to point 3 once you've reached.point 3 the pressure in the left.ventricle exceeds that of the pressure.in the aorta the aortic valve opens and.you have flow out of the LV into the.aorta from point 3 to point forward.during systole the difference between.the end diastolic volume and the end.systolic volume is your stroke volume.and the area here shaded in gray is your.short work this line here or a curve.represented by Emacs is your load.independent contract ility and EA is.your effective arterial elastance which.is a barometer closely related to.afterload so now that we understand.steady States let's talk a little bit.more about what happens with acute MI.and cardiogenic shock in.setting of a cute Imai as you can.imagine your load independent contract.ility curve drops.as a result you have increases in left.ventricular end-diastolic volume and.pressure which is what we see when we.drop a pigtail at the end of our.coronary pci cases and subsequently you.have a decrease in your stroke volume.cardiogenic shock is essentially a qmi.on steroids you have a significant.decrement in your load independent.contract ility you have a rightward.shift of your entire pressure volume.loop curve with a concomitant decrease.in your stroke volume and elevations and.left ventricular pressures and volumes.with that relationship essentially being.heightened the further right you go.with devices well with balloon pump by.nature of how it works you have a slight.decrease in the arterial elastance you.know you're decreasing that afterload.which is why we use it as a modality for.left ventricular decompression your load.independent contract ility doesn't.really change much and that much is true.for LVAD and ECMO but you do increase.the stroke volume just a little bit.again kind of smaller changes but.sometimes it might be enough in the.setting of LVAD you're bypassing the.left ventricle right you're pulling.blood out of the apex and dumping it.into the aorta and so as a result your.pressure volume loop curve really shifts.to the left you have significant.decreases in left ventricular pressure.and volume which can be human a mcli.favorable in a heart that just can't do.the work on its own and then finally.ECMO in the world of PV loops can.sometimes be viewed as a necessary evil.in that the hem dynamic changes in this.regard can sometimes be unfavorable in.that when you see the arterial elastance.that increases which makes sense right.particularly in the setting of.peripheral cannulation again which is.what we see most often you're providing.a counter current flow to the natural.blood flow down the descending aorta.consequently your stroke volume.decreases a little bit in your LV.pressure and volume increase and that in.the setting of cardiogenic shock or.acute MI or cardiac arrest can be.unfavorable it can increase left.ventricular distension it can result in.supply demand mismatch issue issues and.ongoing ischemia especially if there's.on addressed coronary disease and it can.lead to backward flow in the way of.pulmonary edema or this phenomenon we.call ECMO lung.that effects is further corroborated or.supported by what happens when you.continue to crank up the ECMO flow.without dealing with those side effects.as you see moving to the right you're.going from 1.5 to 3 to 4.5 liters per.minute you know you're slowly shifting.up this pressure volume curve you're.increasing the effective arterial.elastance and your stroke volume is.dropping we see this all the time.upstairs and so how do we deal with it.well we decompress the left ventricle.okay we decompress the left ventricle.and how do we do that well there are a.couple different strategies you can try.and increase forward flow either by the.use of high note ropes or titration of.such you can implement in Pella.you can decrease the preload either by.diuresis or ultra filtration try and.decrease the after load like in the.example we saw with the balloon pump you.can tie and try and titrate the ECMO.down so turning down the flow as long as.it doesn't affect your mean arterial.pressure or you can think about.mechanical decompression either by.transept or cannulation or atrial.septostomy or 8lv apical venting which.is pictured here in this figure alright.we know the basics we've looked at the.hemodynamics let's talk about the.objectives indications and.contraindications to ECMO use innie CPR.if you leave today with nothing else.please leave with this ECMO is a bridge.and just like any bridge you see it.can't be a bridge to nowhere okay it.should be a bridge to something and that.something is listed here and further.illustrated in this table and that it.can be a bridge to recovery right it can.buy you time while you're waiting to see.if organs are gonna recover which bleeds.a little bit into the bridge to decision.right after you know a patient suffers.some sort of catastrophic event you're.trying to determine you know are they.going to recover is this end organ going.to recover you can bridge to a more.durable bridge in the way a durable.mechanical support like LVAD or you can.bridge to transplant but all these.things are bridging to something right.just incredibly important to keep in.mind because it helps your decision.making and should I put this patient on.ECMO if they're not a candidate for any.of these things it probably shouldn't go.on ECMO.here are some common indications though.certainly not all encompassing cardiac.arrest in the way of a CPR which we'll.get to here shortly.acute MI myocarditis failure to wean.from cardiopulmonary bypass graft.failure rejection.here are some contraindications has some.relative and some absolutes and store.stage organ failure disease to a history.of ESRD or metastatic cancer end stage.heart failure without option or.transplant or durable mechanical support.again that kind of Bridge to Nowhere.concept goals of care scenarios and this.is incredibly important and why we loop.our palliative medicine team and from.day one to sit down with families and.say you know is this something that they.would want if they're sitting here with.you know me and your family you know we.want to make sure we're doing everything.right by the patients and this plays a.large role in helping determine who is a.candidate for a chemo and who should.continue to be on ECMO support some of.the other things listed again.contraindications systemic and a.correlation aortic dissections fear.peripheral vascular disease all.important things to keep in mind when.assessing these patients up front one.predictor is a morbidity and mortality.that borne out in the literature thus.far older age longer support time higher.lactate concentrations COPD renal.failure requiring CRT hepatic failure.now let's shift gears a little bit and.hone in specifically on e CPR.ICI PR is defined as extracorporeal.cardiopulmonary resuscitation and is.really used in the context of refractory.cardiac arrest which in general can be.defined as sustained cardiac arrest.without return of spontaneous.circulation.despite usually a ACLs cares.including shock if appropriate and.antiarrhythmic use now the two.definitions of the bottom are critically.important and have been shown to be such.in the literature in improving the.chances of neurologically favorable.survival and those are no flow time and.low flow time no flow time being time.from arrest to cpr initiation in low.flow timing time from CPR initiation to.VA ECMO cannulation both incredibly.important here are the general steps to.a CPR from start to finish you know.certainly with some variety in the.middle but you start with activation.then cannulation following cannulation.the real work begins in the CICU weaning.if they can and if they can't.consideration for you know what are we.bridging - maybe that's transplants or.LVAD if you're bridging - nothing or if.you're bridging - decision and the.patient does not recover then maybe.withdrawal of care if you're able to.wean the patient off of the circuit then.D cannulation and hopefully ultimately.discharge.Oh grab we know the objectives let's.talk a little bit specifically about MH.is approach to ECP our management and.it's brief experience in its use so I'm.going to just step through kind of some.of the stages that I'd listed on the.prior slide but in the way of activation.the inclusion criteria here include.bystander CPR within five minutes of.arrest have to be 18 to 75 years old.you have to have a transfer from scene.to MHI time of less than 30 minutes for.cannulation and a total CPR time of less.than 60 minutes exclusion criteria list.a couple of things that we mentioned.before DNR DNI order or known terminal.illness that again would be a.contraindication for moving forward and.this team is really working under the.same mantra as the level 1 activation.team that we use for STEMI protocols and.that time is myocardium and we want to.cannulate these patients as soon as.possible which in part is you know.having a good activation team which is.in part and discussing with EMS.providers the importance of you know.getting these patients on the rig and.transferring them in here in an emergent.fashion also that they can get upstairs.and we can you know begin the recovery.process and the support process on VA.ECMO all the while as you can imagine.appropriate ACLs care should ensue these.including mechanical CPR with Lucas.device which occurs in all patients.taken care of here and all patients are.also cooled externally and then just.general labs are sent off in preparation.for cannulation I mentioned the.different locations that cannulation can.occur at nhi exclusively occurs in the.cath lab with configuration being the.vast majority of cases by femoral.cannulation we use ultrasound and.fluoroscopic guidance I mentioned the.size of the cannula that are typically.used all patients receive a heparin.bolus prior to initiation of flow we.stop and say you know would this patient.benefit from revascularization certainly.the case in the context of acute MI.STEMI or an STEMI or high suspicion for.that being the you know original.etiology for refractory cardiac arrest.and then a distal perfusion catheter can.be placed I think originally was placed.in all patients but now being placed.only in those that show either a.peripheral saturation level less than 50.percent or 20 percent less than the.contralateral limb and this distal.perfusion catheter is placed in the same.limb that your inflow excuse me your.outflow arterial cannula sitting in as.you can imagine this counter current.floo and this large cannula sitting in.your lower limb artery can effectively.occlude or decrease the forward flow.down the rest of the Lemp which can lead.to ischemic complications etc once.you've cannulated successfully we move.on to CICU management and our shock team.at MH is comprised of advanced heart.failure doctors cardiothoracic surgeons.vascular surgeons interventional.cardiology with a couple of their.specific roles listed here the advanced.heart failure team you know certainly.acts as the quarterback for this for.this squad though I do want to highlight.the perfusionist and nursing staff is.they really act as the frontline and.caring for these patients and are just.so critically important and you know.identifying possible complications.updating appropriate providers on what's.going on throughout the day and really.helping us achieve success when caring.for these critically ill folks so hats.off to them.complicated.which I alluded to earlier it can.include limb ischaemia vascular.complications stroke bleeding infection.and then that notion of Harlequin.syndrome which I was speaking to earlier.when I was discussing the merits of Vav.cannulation so again this can occur when.you know you have a RDS or fulminant.respiratory failure and then you also.have cardiac failure necessitating the.implementation of VA ECMO well over time.sometimes the heart recovery you know.beats the recovery of the lungs in that.you have improvement in you know load.independent contract ility or intrinsic.cardiac function which essentially.pushes deoxygenated blood right because.the lungs really aren't doing much in.the way of oxygenating the blood pushes.deoxygenated blood down the descending.thoracic aorta and thus shifts this kind.of mixing cloud of oxygenated blood from.the circuit and deoxygenated blood.coming from the native heart further.down the thoracic aorta as a result you.start to get deoxygenated blood towards.the brain and the upper limbs you get.this kind of you know blue up top and.red it on the bottom Harlequin like.syndrome which can be mitigated by a.couple different strategies one you can.try to increase the ECMO flow a little.bit understanding the effects that.you're going to have on the.pressure-volume loop and maybe lead to.left ventricular distension and the side.effects that come along with that or you.can add a return cannula an additional.outflow cannula to the right side of the.heart so you're having oxygenated blood.flow into the right side pass through.the lungs again the lungs aren't really.doing anything but the vasculature is.still there dumping into the left.ventricle and then exiting left.ventricle so you're having oxygenated.blood reach the upper extremities and.the brain.weaning weaning is considered after.about a day of human Amex stability and.if there's presence of a pulse pressure.over 20 we use echocardiographic.criteria and a swan-ganz catheter to.help guide us all patients get happened.during the weaning process heparin bolus.and flow was weaned about 0.5 to 1 liter.every five minutes with serial imaging.and serial recording of what you know.hour by band tricular systolic function.looks like what the you know left.ventricular dimensions look like.valvular assessment is critically.important and then hue dynamic data in.the way of pulmonary pressures cardiac.output etc patients will move forward.with D cannulation if they maintain a.map over 60 and have an ejection.fraction over 20% or at least around 20%.but the cardiac index that's preserved.on about moderate you know inotrope and.beza pressure support if during the.weaning process you have a decrement in.your map you want to abort and reassess.and if the patient is ECMO dependent.after 5 days usually start thinking hard.about LVAD or whether or not they would.be a candidate for transplant now.to dr. rena watts and our wonderful m.hif research team i'm able to present.some of MH eyes data on its experience.thus far with EC PR.and as or at least in context or for.some context rather MHI sees over.seventy out of hospital non traumatic.cardiac arrests per year in between 2012.and 2017 26 patients were essentially.enrolled in our ECP our protocol with.eight of those arrests occurring in the.cath lab 11 in hospital and 7 out of.hospital and again these are refractory.cardiac arrest patients the average age.was 59 with 65% of these patients being.male and traditional risk factors being.prevalent as you can imagine and as.listed here.hmm all of these patients suffered.witnessed cardiac arrests they all.underwent bystander CPR initial rhythm.was ventricular fibrillation or.tachycardia and 65 percent of all.patients and 83 percent of survivors.compared to 25 percent of non survivors.and time from arrest to ECMO flow is 51.minutes for the entire cohort 46 minutes.and those that survived with a longer.time in those that did not 17 patients.were revascularize at the time of.cannulation seven of whom had arrested.in the cath lab.30-day in six months survival was 69%.the majority of which had a CPC score of.one or two so neurologically.functionally favorable 69 percent of.patients required greater than three.units of blood in a 24-hour period and.only 23% suffered major vascular.complications requiring surgical.intervention here the cam survival.curves with for the entire cohort which.is 69 percent and then broken down into.site of arrests with 88 percent survival.in the cath lab group 71 percent out of.hospital and 55 percent in hospital and.just for some context and comparative.purposes I want to highlight a few other.groups experiences with the caveat that.this is not comparing apples to apples.right each Center really has kind of.different inclusion criteria and.protocols for carrying these for these.patients but really we're relying a lot.on observational data in this setting.because it's all we have thus far and so.with that being said our first two.groups of Ollie and hernia published.their five-year experiences with ECP are.in the context of refractory cardiac.arrest with 18 and 26 out of hospital.cardiac arrest patients respectively in.a mixture of initial rhythm being VF or.VT with an out-of-hospital survival rate.somewhere between five and fifteen.percent in an in hospital cardiac arrest.survival rates around 45 percent.comparatively stubb at all in 2015.published their experience over a.three-year period with all patients.being cannulated in the emergency.department and all patients suffering.from a VF or VT event as their initial.rhythm out of hospital cardiac arrest.survival here was 45% and in hospital.cardiac arrest was 60% now doctor yeah.Annapolis and the University of.Minnesota with their Minnesota.resuscitation consortium published their.data on their one year experience with.cannulation occurring in the cath lab.again all patients suffering VF or VT is.initial rhythm.with an out-of-hospital cardiac arrest.survival rate to 45% with 42% having a.CPC score of one or two I think the.biggest thing you can draw from this.table and the comparisons is the.variability of results and the fact that.we just don't know who the best patient.is yet that should undergo this EC PR.protocol this is how our data has shaken.out so far with just a few important.caveats to keep in mind when.interpreting that data first and.foremost this is a very small sample.size of 26 patients and it's incredibly.difficult to determine whether or not.these results would continue to be.sustained with a larger cohort we've had.about 75 or 76 patients since 2017.undergo ECP are here at MHI with a.survival rate around 44% no lower than.initial experience though certainly not.unexpected and still higher than the.average is seen across the nation all of.these patients suffered witnessed.cardiac arrest again that's critically.important you know some of these.experiences don't stipulate whether the.arrest was witnessed or not and if they.do you know it usually pretends to the.fact that they've received some sort of.bystander CPR again decreasing that no.flow and low flow time which we've.already discussed is so critically.important in improving neurologically.functional favorable survival speaking.to that all these patients underwent.bystander CPR which again you know makes.them even more selected and beyond that.fact all but one received immediate.bystander CPR that patient receiving CPR.after three minutes of downtime so still.within the five minutes that we deem.necessary for inclusion that essentially.eliminates that no flow time.there is a large number of cath lab.arrests in this cohort where arterial.access has already obtained and thus.cannulation can occur efficiently in.revascularization can subsequently occur.if indicated and then again our.inclusion criteria.well strict in that you know these.patients should receive bystander CPR.within five minutes etc still only 26.patients were enrolled over a five year.period or were teams you know.appropriate for a CPR and that really.speaks to the subjectivity in the.selection bias and that we rely heavily.on our shock teams determination and.eyeball tested you know who is going to.be a great candidate for a CPR who maybe.won't be and the hope is as the cohort.grows we can retrospectively look back.and say you know these factors were.critical in determining in which.patients fly in at home which don't in.an effort to hopefully standardize that.decision-making process and replicate.the results that I make I have seen.those far.with all new therapies larger.multicenter randomized trials are needed.the randomized part is certainly ongoing.I don't know if there are any.multicenter trials just yet.because you can imagine it's such a.difficult thing to study given the time.dependence of decision making etc so.circling back to our young Taekwondo.instructor you know she's enroute to the.cath lab she has no pulse and no.perfusing rhythm we have no more tricks.in our ACLs algorithm certainly a.contour a case where we would think.about the utility of v AK Maurice EPR in.the cath lab she was found to have.critical high-grade stenosis and the.left main LED and near complete.occlusion left circumflex with concern.for spontaneous coronary artery.dissection with some concomitant.thrombosis.from ectomy was attempted though.unfortunately complicated by perforation.of left circumflex which is shown here.and this kind of blush a die you see.above the circumflex artery this was.subsequently treated with a three by 20.balloon and as you can see the Lucas.device is still running we have yet to.achieve in a perfusing rhythm or Rask.and thus the decision was made to.proceed with a CPR cannulation and VA.ECMO here on your right you see the the.peripheral cannulation occurring with.the the perfusion catheter being placed.in the same land that the arterial.catheter candle is being placed in.subsequently it was turned back to the.coronaries since now we've cannulated.we've achieved a map of 65 shortly after.which we achieved to perfusing rhythm.they'll be at the cardiac function which.you can tell even here on these in.geographic images is quite poor a.covered stent was placed in that left.circumflex artery to manage the.perforation and further.revascularization was really deferred in.the context or concern of propagation of.that dissection down the remainder of.the coronary tree.here's the patience post-pc ICT as you.can see there's already evidence of you.know fulminant pulmonary opacities.bilaterally with you know likely.developments uh Verdi s down the line.and also just a nice picture of your.venous cannula placement which usually.resides within the right atrium or at.the SVC are a junction post PCI ECG.shows those Q waves that we noted an.initial EMS strip now in sinus still has.some persistent St elevation and the.high lateral leads and kind of diffused.ischemic changes elsewhere.here's her post PCI echocardiogram you.know no surprise here we already saw it.on the angiogram the LV function is.severely reduced the RV actually is.pretty decompressed in this setting.which is not uncommon in the context of.you know immediate VA ECMO cannulation.and that these patients just need a lot.of fluid.you.here's her Hospital course troponin.peaked at 950 she developed na na.leaguer renal failure requiring CRT air.D s shock liver di sì shí a compartment.syndrome requiring bilateral.fasciotomies and cerebellar stroke with.really unclear neurologic status.as you can imagine and as we spoke about.earlier pileated is so critical in these.patients and we sat down both with the.palliative team and the family members.and said look you know GARP prognosis is.extremely guarded in this situation and.you know while we're seeing maybe some.recovery in some areas were certainly.not out of the woods hospital died 11.she was opening her eyes but not really.tracking but hospital day 13 she.squeezed someone's hand with a little.bit of light and sedation and.miraculously by day 15 she was reliably.following commands.again extensive discussions with family.you know these are promising signs but.has End Oregon you know failure is still.requiring a lot of support ultimately.she underwent LVAD placement on Hospital.day 31 with concomitant D cannulation at.that time and went from unable to.achieve roske.to discharging to encourage Kenny on.Hospital day 71 and in June of 2015 she.got a heart transplant.she was seen in clinic sometime the last.couple months was doing really well is.working independent and has no cardiac.funk cardiac symptoms excuse me plenty.of cardiac function at this time so.certainly anecdotal but powerful it.shows you you know what this technology.can do when applied to the right case so.in conclusion we went through the basics.of VA ECMO and its history we went over.the hemodynamic security genic shock in.vehicle we talked about the common.objectives indications and.contraindications to the ECMO you see.CPR and we also highlighted MH eyes.approach to ECP our management and.experience thank you but feel free to.submit questions via the Q&A pod located.at the bottom of your screen thank you.you know look at the 26 patients that.you presented from our experience and.that table went by me pretty fast but.how many of the survivors had asystole.or PE a versus like a shockable rhythm.did it was a difference there and then.how many of those 26 worth were an acute.ST elevation mi yep so to answer your.first question the percentages here and.again sorry I click through somewhat.quickly those patients so out of the.entire cohort and.nine patients or 35% head PA or asystole.okay and and three of those patients.survived to discharge now you know.historically we look at ventricular.fibrillation or tachycardias or you know.shockable rhythm as in there's hopefully.some sort of reversible cause now that's.you know not saying that you can't have.some sort of myocardial scarring from a.prior you know CA da related event etc.but the hope is in this context as.you're alluding to that you know there's.something to fix from a coronary.standpoint and you know I think in the.literature we've seen a trend you know.and the patients that actually get.revascularization appropriate.revascularization for acute lesions and.not just well you know there's maybe a.stenosis here that could have.contributed you know those patients tend.to do better but really at the end of.the day it's all about what goes on.upstairs right we you know think we.manage a lot of things and have you know.a lot of impact on increasing the.chances of neurologically functionally.favorable survival and you know quicker.cannulation Reve aster izing when.indicated etc but you know the brain is.still somewhat of a black box you know.we're trying to cool we're trying to you.know get the brain as much oxygen as.quickly as possible in the way of you.know decreasing low flow and no flow.times but the reality is even if you.have here asystole it all depends on you.know how the brain does at the end of.the day and that's what you know often.times we're waiting to see we'll recover.now the differences between mm between.VF & VT bear out a little bit here and.you know our small cohort of 26 but I.imagine would be even more pronounced if.we look back in the addition of the 75.patients or so that we've had cannulated.in the ECP our protocol since 2017 oh.yes to your second question I think the.actually a large number of this cohort.for STEMI or n STEMI I don't think a.huge amount or STEMI I think certainly a.lot more n STEMI as you can imagine than.STEMI I can't quote the exact number but.I can get back after this conference.yes.one line questions so far and it is what.is the role of hypothermia that's a.great question you know as I was.mentioning it's really all about brain.recovery and preserving a neurologic.function in this context and so in our.cohort we cool all patients if we can if.you know unless there's some absolute.contraindication to not cooling and I.think targeted temperature management.has been shown to be most effective in.those patients that suffer cardiac.arrest with a you know shockable rhythm.in the way of VT or VF though the.results have been conflicting.historically in the literature on its.efficacy and those patients that suffer.from PA or asystole regardless I think.if they can Heymann a mcli tolerate it.we try to be as aggressive as possible.just in that you know we want to give.the brain the best chance it can to.recover under these circumstances thank.you.another question from dr. Burke is has.anyone considered extending the time for.CPR the patient is receiving CPR with.Lucas yeah that's a good question so we.use Lucas device ubiquitously here I.think in the literature it hasn't borne.out clinically to show you know much in.the way of difference from survivability.standpoint I think experimentally it.does or has been shown to improve the.amount of oxygenated blood or a brain.oxygenation that you see but again.that's in the experimental context I.don't know if there's been discussion.about you know lengthening the amount of.time from CPR to cannulation for the.criteria standpoint though certainly I.mean just like any guideline or criteria.there can be discussion right you can.all agree that this patient is out of.protocol you know even though they may.be five minutes outside of our technical.protocol boy they came in said I'm.having chest pain I'm having chest pain.the suspicion for underlying you know.acute coronary syndrome is quite high we.think this is something that we can.treat we think this is something that's.reversible so that's a good point in.that it also brings up you know maybe a.little bit of flexibility in that.context to say you know while this.patient doesn't perfectly meet criteria.you know we think they'd be a good.candidate for CC PR anyway.thank you.

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Do you have to fill separate forms for each institute participating in the MH-CET/MBA or just the examination form?

Just the examination form would suffice as an application to all institutes participating in the CAP (centralized admission process) rounds. For institutes that are not under CAP and for other courses like pgdm you need to fill separate forms; official websites of colleges you are targeting will provide you the necessary information.

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