ACLS GOES ECMO

We had a young man with cardiac arrest brought in to our hospital. He had been alternating between VF and spontaneous circulation during resuscitation. As an emergency rescue attempt enroute, he had received thrombolytics. At arrival in our hospital, he was taken to the cath lab and after stenting his LAD, he received more anti-thrombotics. He then started to bleed from his lungs. A lot. He was dying fast. Until he was put on V-A ECMO.

Background
It was a witnessed arrest of a male in his fourties, and CPR was started immediately. Our HEMS response team were there within 7 minutes. They continued CPR and the patient was tubed, shocked back to ROSC, but went back into VF several times. He had been resuscitated for 50 minutes, in and out of spontaneous circulation and still had small pupils reacting to light, when he got into our PCI lab and had his LAD occlusion opened. But prior to this he had received thrombolytics as an emergency rescue attempt enroute – and after the stenting he got integrilin and other powerful anti-thrombotics. He then proceded to bleed from his lungs. 4 litres in total. Of course, his ventilation wasn’t optimal during this profuse bleeding. His paO2 reached 3.6kPa. His heart was struggling. He was dying fast. The decision was made to put him on ECMO. There was talk of V-V ECMO, but due to his struggling heart, we landed on V-A ECMO.

Lung protection V-A ECMO
Of course, the ECMO fixed his oxygenation problem – and also fixed his blood flow, which was suboptimal from his stunned and failing heart. Another great side effect possibly attributed to the V-A ECMO was that the bleeding from his lungs stopped shortly after putting him on the circuit. My thinking is that the ECMO circuit took a lot of the pressure of his lung circulation. A lot of the blood was now sucked out of the right atrium and into the ECMO circuit and pumped back into his aorta, bypassing the lung circulation. This also left his failing heart to work with a smaller load, and coping with the remaining blood from the lung circulation and managing to pump it into the systemic circulation. Thus the pressure in the lung circulation fell and allowed clots to form and stopped the bleeding. His lung x-ray went from horrible to acceptable within the next 24hrs. This was helped by a lot of TEG guided clotting factors and a bronchial lavage.

Full recovery
He stayed on ECMO for 36 hrs. The weening was uneventful. He had a further couple of days intubated. He was taken off sedation and gradually came to over the next few days, but slightly confused and agitated. His head MRI was normal 9 days after his arrest, so everything was looking promising. He is now close to having a full neurological recovery. His lung function is good and is not giving any problems. His heart has localised akinesia agreeing with an acute LAD occlusion, but still with an EF of 40%. All in all a success story that would never be without ECMO. ECMO can fix anything.

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