Multi-Dose Activated Charcoal Part 2/2

fresnotox@gmail.com (Rais Vohra) — Thu, 24 Oct 2013 15:59:00 -0700

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Multi-Dose Activated Charcoal Part 1/2

fresnotox@gmail.com (Rais Vohra) — Thu, 24 Oct 2013 15:59:00 -0700

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Best Scientific Abstracts from NACCT 2012

fresnotox@gmail.com (Rais Vohra) — Thu, 24 Oct 2013 15:57:00 -0700

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Carbon Monoxide and the Heart Journal Club

fresnotox@gmail.com (Rais Vohra) — Thu, 24 Oct 2013 15:56:00 -0700

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Snakebites Journal Club

fresnotox@gmail.com (Rais Vohra) — Thu, 24 Oct 2013 15:51:00 -0700

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Cyanide Journal Club

fresnotox@gmail.com (Rais Vohra) — Thu, 24 Oct 2013 15:51:00 -0700

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High Dose Insulin Therapy

fresnotox@gmail.com (Rais Vohra) — Thu, 24 Oct 2013 15:19:00 -0700

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ECMO in Poisoning Journal Club

fresnotox@gmail.com (Rais Vohra) — Sat, 5 Oct 2013 23:45:00 -0700

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We recently had a interesting toxicological case that involved ECMO, so we’re going to discuss the utility of ECMO in poisoning.

Case

7 month old child with a history of ectopic atrial tachycardia was put in the care of his aunt. He is on a strict medication regimen. His aunt gives his usual medication and within a few minutes later, he had become pale and distressed. She calls 911 and the paramedics arrive and on the cardiac monitor, the see the following rhythm:

The EMS find that the aunt had given 4 times the dose of his medication, which was flecainide. The aunt had counted 1 line from the top of the 5 ml syringe rather than from the bottom. He was taken to the hospital and lost pulses. Pt had to undergo CPR and the poison control was consulted. At that point, the poison control center recommended intralipid and sodium bicarbonate. He had a return of pulses afterwards.

At this point, he was started on ECMO. Since this was a poisoning, ECMO could give the child more time to metabolize the flecainide. He was eventually taken off of ECMO on day 3 and child was eventually discharged from the hospital playful and acting like his normal self.

ECMO

ECMO is similar to dialysis. The basic principle is to remove blood, replace what is needed, and return the blood to the body. In the case of ECMO, gas exchange and/or cardiac output are the processes replaced for the body.

Two forms of ECMO exist. There is Venovenous (VV) or Venoarterial (VA) ECMO. For VV ECMO, this is solely replacing the lungs for gas exchange. The blood is removed from a vein, oxygenated, and returned back into the venous system This can be helpful particularly as a salvage therapy when positive pressure ventilation is either ineffective. VV ECMO is also used when patients are unable to handle high inspiratory pressures or pressure/volume limited ventilation strategies.

VA ECMO is where blood is removed from a vein, oxygenated, and then pumped into an artery (usually the aorta). In addition to oxygenating blood, VA ECMO also replaces the heart’s pumping function, so blood is returned at higher pressures to perfuse the rest of the body. VA ECMO is usually reserved for refractory circulatory shock.

Indications for ECMO

According to the Extracorporeal Life Support Organization (ELSO), VV-ECMO should be considered for the following:

Risk of death is > 50% and indicated if >80%.
Murray score >= 3 or 4 associated with 80-90% risk of death (http://bit.ly/1k0BYjf).

ECMO found particularly use during the past SARS epidemic. This parallels poisoning as the patient should improve after given enough time to metabolize the toxin.

Complications of ECMO

The most common complications are bleeding and clotting. As the blood runs through the circuit, risk of clotting and passing emboli increases, so an anticoagulant is used. Overall bleeding complications is 10-36% and intracranial hemorrhage is around 6%. Additionally, red blood cells are hemolyzed passing through the ECMO circuit. On average, patients require about 1 unit of blood transfused per day.

Poisoning and ECMO

Most of the evidence is from case reports. The best evidence we have so far is a non-randomized, retrospective study done in France. All patients had persistent cardiac arrest or severe shock following poisoning due to drug intoxication. ECMO was performed on 14 patients and 48 patients had conventional treatments. 56% of the patients in the conventional arm survived while 86% of the ECMO arm did. After adjusting for Simplified Acute Physiology Score (SAPS II) and beta blocker toxicity, the ECMO arm were associated with lower mortality (OR: 0.18 [0.03-0.96], p =0.04).

ECMO in Action

The “French” model is that ECMO comes to the patient. In France, a doctor is always traveling in the ambulance, which is different from the American “scoop and run” model for EMS. Resuscitation can be done in the ambulance. Additionally, ECMO cannulation can be started in the ambulance or sending site and then finished at the receiving site.

In the book Checklist Manifesto, there was a case of a young girl who drowned but was fished out in 45 minutes. She had no signs of life, but was put on ECMO. Over the course of 6 days, patient recovers back to her normal self. This story illustrates the need for an enormous amount of coordination for ECMO to be successful. However, currently ECMO is only available at certain centers and requires a lot of training and expertise. It is also expensive (approximately $31,000 per patient). Much more clinical and basic science research needs to be done for ECMO before we can consider widespread usage.

An ECMO Poisoning Story on YouTube

References:

Shenoi AN, et al. Refractory Hypotension From Massive Bupropion Overdose Successfully Treated With Extracorporeal Membrane Oxygenation. Pediatric Emergency Care. Jan 2011;27:43-45.
Megarbane B, et al. Extracorporeal life support in a case of acute carbamazepine poisoning with life-threatening refractory myocardial failure. Intensive Care Medicine. 2006;32:1409-1413.
De Lange DW, Sikma MA, Meulenbelt J. Extracorporeal Membrane Oxygenation in the Treatment of Poisoned Patients. Clinical Toxicology. 2013;51:385-393.
Masson R, Colas V, Parienti JJ, Lehoux P. Massetti M, Charbonneau P, Saulnier F, Daubin C. A Comparison of Survival With and Without Extracorporeal Life Support Treatment
for Severe Poisoning Due to Drug Intoxication. Resuscitation. 2013;83:1413-1417.
Goodwin DA, Lally KP, Null DM. Extracorporeal Membrane Oxygenation Support for Cardiac Dysfunction from Tricyclic Antidepressant Overdose. Critical Care Medicine. 1993;21:625-627.
Extracorporeal Membrane Oxygenation for ARDS in Adults. NEJM. Feb 2012;366:575-576.
Marcinak KE, Thomas IH, et al. Massive Ibuprofen Overdose Requiring Extracorporeal Membrane Oxygenation for Cardiovascular Support. Pediatric Critical Care Medicine. 2007;8:180-182.
Brodie D, Bacchetta M. Extracorporeal Membrane Oxygenation for ARDS in Adults. NEJM. Nov 2011;365:1905-1914.
Gawande A. The Checklist Manifesto: How to Get Things Rights. Macmillan Publishers. 2009. Available at: http://us.macmillan.com/BookCustomPage_New.aspx?isbn=9780312430009. Accessed August 5,2013.

FM Journal Club- Peds Lipid and Flumazenil July 2012

fresnotox@gmail.com (Rais Vohra) — Tue, 10 Jul 2012 14:29:00 -0700

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Tox in the FresYes

Multi-Dose Activated Charcoal Part 2/2

Multi-Dose Activated Charcoal Part 1/2

Best Scientific Abstracts from NACCT 2012

Carbon Monoxide and the Heart Journal Club

Snakebites Journal Club

Cyanide Journal Club

High Dose Insulin Therapy

ECMO in Poisoning Journal Club

FM Journal Club- Peds Lipid and Flumazenil July 2012