This document discusses advances in ECMO and REBOA treatment. ECMO provides lung and heart support to allow time for treatment when time is the treatment. It is used for conditions like ARDS, lung trauma, heart attacks, and as a bridge to transplant. Outcomes have improved at ECMO centers. REBOA is the placement of a balloon in the aorta to control hemorrhage from the abdomen or pelvis. It is indicated for trauma with suspected bleeding below the diaphragm and can control bleeding until surgery.

1. ECMO & REBOA:
ADVANCES IN TREATMENT
Joseph Shiber, MD, FACP, FACEP, FCCM
Associate Professor
Director ECMO Service & Co-Director NSICU
Emergency Medicine, Neurology, and Surgery
UF College of Medicine - Jacksonville

2. ECMO Background: since 1972 Adults
• ECMO does NOT fix anything BUT allows time for treatment
• Sometimes Time is the Treatment
• VA for pulmonary & cardiac support
• VV pulmonary: true “lung rest” to allow recovery
• Ultraprotective MV: not relying on lung for gas exchange
• CO2 removal low blood flow (<1L/min) = smaller access
• Oxygenation needs >60% CO (4-6L/min) = larger access

3. Flu A

4. ECMO
• Dual Heart-Lung “bypass” parallel or Only Lung serial
• Lung Rest: ARDS, Asthma/COPD, lung trauma, air leak
• Heart: MI, PE, Blunt Cardiac Injury, Myocarditis, eCPR
• Different configurations for VV or VA
• Two Catheters vs Single dual-lumen catheter

5. VV: Pulmonary

6. VA: Cardiac and Pulmonary

7. Indications
• ARDS: PaO2/FiO2 <80 mmHg despite optimization
• Murray Score: P/F, PEEP, compliance, CXR quadrants
• Hypercapnic respiratory failure: pH <7.20
• Ongoing large air leak
• Refractory cardiogenic shock
• Cardiac arrest with chance of recovery
• Failure to wean from cardiopulmonary bypass
• As a bridge to cardiac transplantation or VAD

8. Severe Blunt Chest w/ TBI

9. VV: Fem/Fem

10. Contraindications
• If the cause is irreversible
• Anticoagulation is contraindicated: bleeding, TBI, ICH
• Respiratory failure: on MV>10 D = poor outcome
• For cardiac failure, if VAD or transplant is contraindicated
• May exclude: advanced age, morbid obesity, neurologic
dysfunction, poor preexisting functional status

13. Outcomes
• Mortality severe ARDS 40-60% w/ ECMO reduced to 25%
• Referral to an ECMO center significantly improves recovery
and survival from severe ARDS!
• 15-25% of patients improve and recover without ECMO
• It is recommended that adult patients with severe ARDS
be referred to an ECMO center, assuming that there are
no contraindications
• Survival w/ GOOD Neuro Fxn s/p Cardiac Arrest ~ 1 - 2% but
~12% w/ ECMO

14. What is the difference?

15. Walking rehab on ECMO

17. Resuscitative Endovascular Balloon Occlusion
of the Aorta
• Placement of an endovascular balloon in the aorta to
control hemorrhage and to augment afterload in
traumatic arrest and hemorrhagic shock
• Endovascular balloons have been used to control
hemorrhage in settings such as aortic aneurysm
surgery, gastro-intestinal bleeding, postpartum
hemorrhage as well as trauma

18. • Tends to cause less physiological disturbance
and have higher rates of technical success than
thoracotomy with aortic cross clamping

19. Anatomy
• Zone I of the aorta extends from the origin of the left
subclavian artery to the celiac artery (approx 20cm)
• Zone II extends from the celiac artery to the most
caudal renal artery (approx 3cm) *NOT a target
• Zone III extends distally from the most caudal renal
artery to the aortic bifurcation (approx 10cm)

21. Anatomy
• Thoracic aorta is 20mm in diameter
• Distal aorta is 15mm in diameter
• Averages 2mm narrower in females
• Increases by 0.5 mm/y
• Zone 1 is measured to the xiphoid
• Zone 3 is measured to just above the umbilicus

22. Indications
• PEA arrest (<10 minutes) secondary to exsanguination
from sub-diaphragmatic hemorrhage and femoral
vessels immediately identifiable on US
• Severe hypovolemic shock and SBP <70mmHg
• Agonal state due to non-compressible exsanguinating
hemorrhage: non/partial responders to rapid volume
resuscitation (causes of obstructive shock excluded)

23. Indications
• Suspected or diagnosed intra-abdominal
hemorrhage due to blunt trauma or penetrating
torso injuries (Zone I)
• Blunt trauma with suspected pelvic fracture and
isolated pelvic hemorrhage (Zone III)
• Penetrating injury to the pelvic or groin area with
uncontrolled hemorrhage from a vascular injury of
iliac or common femoral vessels (Zone III)

24. ER-Reboa: Zone III

25. Contraindications
• Age >70y
• PEA arrest (<10 minutes) secondary to exsanguination
from sub-diaphragmatic hemorrhage and femoral vessels
not immediately identifiable on ultrasound = open chest
• Cardiac arrest due to causes other than exsanguination
due to severe subdiaphragmatic trauma
• PEA arrest >10 minutes
• High clinical/radiological suspicion of proximal aortic injury
• Pre-existing terminal illness or significant comorbidities

26. Procedure Steps
• Access Common Femoral Artery (CFA) using ultrasound (or cutdown)
• Zone I – Xiphoid (approx 50cm)
• Zone III – Umbilicus (approx 40cm)
• Inflate balloon until moderate resistance (document time)
• Zone I – 15 to 20 mL
• Zone III – 10 to 15 mL
• X-ray – confirmation balloon position: 2 radiopaque bands
• Zone I – T4 to L1
• Zone III – L2 to L4
• Secure catheter
• Expedite departure to OR/IR (no CT post-REBOA)

27. Zone I Zone III

28. Equipment: Coda
• Cook arterial line kit
• Percutaneous entry thin-wall needle (Cook: 18G, 7cm)
• Cook 12 Fr sheath kit
• Amplatz Extra-Stiff guidewire (Cook: 0.035 inch, 180cm)
• Cook Coda Balloon Catheter 32mm, 9Fr shaft, 100cm length
• Will need arterioraphy s/p catheter removal

29. Equipment: ER-Reboa
• 7 Fr CFA Introducer
• Prytime Medical 7 Fr ER-Reboa catheter
• Arterial line transducer
• Only need to hold pressure s/p removal

30. UMMS/STC Algorithm

31. QUESTIONS & COMMENTS
REBOA: Dr. Skarupa is Leader at UF Health
ECMO: Shiber, Skarupa, Yorkgitis; Mrs. Young