Zack Shinar - How we do ED– ECMO

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SMACC Conference

ECMO or extracorporeal membrane oxygenation has shown promise in the use of cardiac arrest patients. Zack Shinar and his crew from San Diego have lead the way in emergency physician initiated ECMO for patients in cardiac arrest. In this lecture he explains briefly how ECMO works, what their outcomes have been and where ECMO is moving. Initially 5 of their first 8 patients were neurologically intact survivors. Their first patient had over an hour of downtime when cardiac bypass was initiated. He walked out of the hospital completely neurologically intact nine days later and now has been featured on the film “Code Black”. Physicians from their hospital, Sharp Memorial, were also recently featured on the television show “Untold Stories in the ER” for a save of a 21 year old female arresting from hyperkalemia. Dr. Shinar also discusses some of the latest physiologic questions as the Australians have pushed for smaller diameter catheters that allow for smaller flow volumes. He also discusses how in Paris pre-hospital ECMO is being done by physicians in various places like the subway, apartment buildings and even the Louvre. In the end, Dr. Shinar discusses the biggest question in any novel resuscitation technique: cost. Prolongation of life and particularly after a cardiac arrest is expensive and many people do not survive. Dr. Shinar uses various pioneers in the world of technology to tell how true genius is not in technologic advancements but in making those advancements available to the masses. He ends with a story about Linus Torvalds. Dr. Shinar shows how this man through the use of the collective minds of computer programmers worldwide created one of the best operating systems ever created: Linux. He asks the medical community to endorse this idea and introduces the concept of “free open access medical innovation”.

Health & Medicine

ECMO:
HOW WE DO IT!
Zack Shinar
@ZackShinar
No Financial Disclosures
San Diego, California

RESTORATION OF LIFE

THE ECMO CIRCUIT

ECMO:
HOW WE DO IT!
Zack Shinar
No Financial Disclosures
San Diego, California

RALPH

HOW WE DO IT!

EMERGENCY PHYSICIAN INITIATED ECMO

OUR DATA

WORLDWIDE ECMO

THE PHYSIOLOGY OF ECMO

4.5 L/min or 2.5 L/min
?

THE FUTURE IS NOW
•Stop the “Stay and Play”
•PreHospital Mechanical Compressions

ENDOVASCULAR RESUSCITATION

REBOA AND RESUSCITATIVE
ANGIOGRAPHY

CRITICAL CARE PATIENTS WOULD
SIGNIFICANTLY BENEFIT FROM
TRANSFORMATIVE FISCAL
INNOVATION

WE NEED INNOVATORS

FREE
INNOVATION
OPEN ACCESS MEDICAL

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After spinal cord injury (SCI), there aren’t many interventions we have available that actually make a difference. Augmenting blood pressure to increase spinal cord perfusion pressure is an attractive concept that may improve neurological outcomes following SCI. We know that hypotension can make SCI worse. Clinical studies looking at blood pressure augmentation are mostly old, retrospective and flawed in various ways. Aiming for a MAP of > 85 for 5-7 days is recommended by guidelines but why this pressure and duration are good questions. Hypertensive therapy is relatively safe and easy to implement but not without risk. Tessa discusses the pros and cons, how this is managed practically and what the future may hold in this area.

Hypertensing Spinal Cord Injury - gold standard or wacky?

Hypertensing Spinal Cord Injury - gold standard or wacky?

Hypertensing Spinal Cord Injury - gold standard or wacky?

SMACC Conference

Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient. He discusses the background to CPPopt, including intrcranial pressure (ICP), the Monroe Kelly hypothesis, neurovascular coupling, and cerebral autoregulation in health and following brain injury. He shows how intracranial pressure is affected by intracranial compliance and how this affects ICP waveforms. Cerebral perfusion pressure in relation to the Brain Trauma Foundation guidelines is covered including management of elevated ICP (EICP). The currently recommended tiered approach to managing cerebral perfusion pressure and EICP is mentioned citing recent guidelines. He uses a clinical case of a TBI to illustrate how the CPPopt can be ascertained and used to guide therapy, including the easy to perform “MAP Challenge”. Mark also describes the Pressure Reactivity Index (PRx) and how it can be used as a target for therapy. Finally, he covers the exciting results of the preliminary COGiTATE pilot study.

Optimal Cerebral Perfusion Pressure

Optimal Cerebral Perfusion Pressure

Optimal Cerebral Perfusion Pressure

SMACC Conference

The Power of Words - Death and Language.ppt

The Power of Words - Death and Language.ppt

The Power of Words - Death and Language.ppt

SMACC Conference

Appropriate use of antimicrobials is primarily a patient safety issue, and is the key aim of an effective antimicrobial stewardship program. We discuss the challenges in the management of a patient with sepsis, and how decision-making is usually done in the absence of effective diagnostics. Time dependent protocols and the knowledge that undertreatment of a patient with sepsis will lead to poor outcomes will lead to prescribing that may be driven by fear. Antimicrobial resistance is associated with over-use of antimicrobials but is usually not the immediate concern. Antimicrobial stewardship programs should work closely with sepsis teams to ensure that sepsis pathways are implemented across the whole hospital, and that key principles of judicious use are embedded within the clinical pathway.

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

SMACC Conference

Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources. However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task. Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome. Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models. There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases. We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.

Brain injury outcomes and predictors

Brain injury outcomes and predictors

Brain injury outcomes and predictors

SMACC Conference

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Precision Medicine in Acute Brain Injury

Precision Medicine in Acute Brain Injury

Precision Medicine in Acute Brain Injury

CSD by Jeffcote Coda 22.pdf

CSD by Jeffcote Coda 22.pdf

CSD by Jeffcote Coda 22.pdf

Subdural Haemorrhage and MMA embolisation

Subdural Haemorrhage and MMA embolisation

Subdural Haemorrhage and MMA embolisation

Andy Neill - More neuroanatomy pearls for neurocritical care

Andy Neill - More neuroanatomy pearls for neurocritical care

Andy Neill - More neuroanatomy pearls for neurocritical care

The BONANZA Trial and PbTO2 Monitoring

The BONANZA Trial and PbTO2 Monitoring

The BONANZA Trial and PbTO2 Monitoring

Dilating the Dogma of Vasospasm

Dilating the Dogma of Vasospasm

Dilating the Dogma of Vasospasm

EVD Tips and Tricks

EVD Tips and Tricks

EVD Tips and Tricks

There is no such thing as mild, moderate and severe TBI - by Andrew Udy

There is no such thing as mild, moderate and severe TBI - by Andrew Udy

There is no such thing as mild, moderate and severe TBI - by Andrew Udy

TBI Debate - Mild, moderate and severe categories work

TBI Debate - Mild, moderate and severe categories work

TBI Debate - Mild, moderate and severe categories work

TBI: when to stop and when to give time

TBI: when to stop and when to give time

TBI: when to stop and when to give time

Ketamine in Brain Injury by Toby Jeffcote

Ketamine in Brain Injury by Toby Jeffcote

Ketamine in Brain Injury by Toby Jeffcote

Managing Complications of Chronic SCI by Bonne Lee

Managing Complications of Chronic SCI by Bonne Lee

Managing Complications of Chronic SCI by Bonne Lee

EEG and Status Eplilepticus by Tania Farrar

EEG and Status Eplilepticus by Tania Farrar

EEG and Status Eplilepticus by Tania Farrar

Browne Neuro symposium.pptx

Browne Neuro symposium.pptx

Browne Neuro symposium.pptx

Paediatric Stroke by Shree Basu

Paediatric Stroke by Shree Basu

Paediatric Stroke by Shree Basu

Hypertensing Spinal Cord Injury - gold standard or wacky?

Hypertensing Spinal Cord Injury - gold standard or wacky?

Hypertensing Spinal Cord Injury - gold standard or wacky?

Optimal Cerebral Perfusion Pressure

Optimal Cerebral Perfusion Pressure

Optimal Cerebral Perfusion Pressure

The Power of Words - Death and Language.ppt

The Power of Words - Death and Language.ppt

The Power of Words - Death and Language.ppt

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

Brain injury outcomes and predictors

Brain injury outcomes and predictors

Brain injury outcomes and predictors

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