BY LIONEL LAMHAUT, MD, PhD
For decades, extracorporeal life support
(commonly referred to as extracorporeal
membrane oxygenation, or ECMO) was
used in the operating room (OR) and ICU
to treat refractory shock, typically after
surgery. More recently, ECMO has been
used to treat refractory cardiac arrest; in this
indication, it takes the name “ECPR.” Today,
ECPR is used in many places.
Although there are published case
reports, series and after/before studies,
there have been no randomized controlled
trials to illustrate its effectiveness in the
resuscitation of out-of-hospital cardiac
arrest (OHCA) patients.
However, ECPR is now recommended by
international guidelines in the management
of refractory OHCA of suspected reversible
cause, such as acute myocardial infarction,
refractory cardiac arrest of suspected
reversible cause, pulmonary embolism and
intoxication.1 The 2015 American Heart
Association Guidelines recommend ECPR
could be considered in refractory cardiac
arrest of suspected reversible cause. 2
ECPR is the second line of treatment for
OHCA not responding to usual BLS and
ALS treatments (e.g., cardiac compressions/
massage, ventilation, defibrillation,
drug administration, etc.). ECPR brings
respiratory and circulatory support,
ensuring sufficient blood and oxygen supply
to the whole body, especially the brain.
The ECPR response team in Paris
implements ECMO on scene to restore
blood flow to the body and limit ischemic
consequences to the brain and coronary
arteries. The hybrid implementation
technique used by Service d’Aide Medical
d’Urgence (SAMU) in Paris, which uses a
surgical cutdown followed by insertion of
the cannula in the femoral artery, is quick,
safe and accessible to emergency physicians,
with low failure rates. 3
Selection of Patients
Eligible for ECPR
ECPR is a neuroprotective treatment.
Neuroprotective treatments are therapies
that block the cellular, biochemical and
metabolic elaboration of injury during
or after exposure to ischemia and have a
potential role in ameliorating brain injury
in patients with acute ischemic stroke. 4
Patients with neuroprotection need
to be cannulated. These patients include
hypothermia below 32°C, intoxication (with
neuroprotection) and general anesthesia.
For other patients, the selection needs
to be based on brain criteria. At this time,
the selection criteria include “signs of
life” (e.g., breathing movements, gasping,
spontaneous movements and pupillary
reactivity). Other criteria like no flow and
rhythm aren’t related to the prognosis.
The quality of the CPR is crucial, as is the
quality of care after ECPR.
Who and Where?
Today surgeons, intensivists,
cardiologists and emergency physicians
can perform ECPR. However, new
ECMO devices may enable highly trained
prehospital clinical specialists to perform
ECMO in the field.
The objective of ECPR is to get the patient
on ECMO within 60 minutes of an OHCA.
If a patient has some persistent signs of
life, they can undergo ECPR at any time.
For neuroprotected patients, the low flow
time can be very long (e.g., five hours of
The location to initiate ECPR insertion
is usually the OR, ICU or ED, and insertion
can be done by surgical technique,
percutaneous under ultrasound control
or by a hybrid technique. The location for
ECPR needs to be selected based on the site
most advantageous to reduce the low-flow
time. Since 2011, some teams in Europe have
started to do prehospital ECPR with good
results, in order to reduce the low-flow time.
In 2018, all communities should have
a pre-established protocol of ECPR for
selected refractory cardiac arrest patients.
This protocol needs to describe the selection
criteria, the technique of insertion and the
site of insertion. This protocol should try to
reduce the period of low flow. Prehospital
ECPR can be done effectively and should
be considered when adequately trained
medical personnel are available. This
protocol needs to be collaborative with
EMS, ED, ICU and cardiologists. ECPR
has the potential to significantly increase
survival rates when incorporated into an
optimal OHCA bundle of care. ;
For a complete list of references and a bio of the
author, go to www.jems.com/THA
Since 2011, the ECPR response team in Paris
may implement ECMO on scene to restore
blood flow to the body and limit ischemic
consequences to the brain and coronary arteries.
PHOTO COURTES Y SERVICE D’AIDE MEDICAL D’URGENCE
(SAMU) DE PARIS
Figure 1: Effect of implementing ECPR patient
selection criteria and protocol in Paris5
“Selection” is the patient selection criteria.
“Protocol” refers to the combination of
prehospital ECPR, epinephrine ≤ 5 mg, and