PCI center with ongoing mechanical chest compressions may change how refractory cardiac arrest
victims are treated.
Success of such programs, particularly in the
beginning, will depend on careful selection of
appropriate patients. This novel approach consists of rapid transport of refractory out-of-hospital
v fib cardiac arrest patients with mechanical chest
compressions in route to the destination of an
ECLS-capable medical facility, where rapid introduction of circulatory support can be achieved in
either the ED or catheterization lab.
Simultaneous induction of therapeutic hypothermia (34 degrees C) and coronary angiography and PPCI are crucial to correct the underlying
cause of the refractory arrest, and to ensure optimal neurological function of survivors.
Continuing ECMO support for the profound
post-resuscitation left ventricular dysfunction
associated with prolonged cardiac arrest is also
critical to achieve long-term positive outcomes
with this approach.
Early reports, though admittedly containing
small numbers, suggest significant improvements
in neurologically intact survival can be achieved
with this new paradigm of “load and go” or “scoop
and treat on the way.”
EMS agencies and their medical directors are
encouraged to work with their specialty hospital
facilities, as they have in Alameda County, Calif.,
to ensure that ECMO capabilities are available and
can be alerted similar to prehospital STEMI alerts,
to be able to fulfil this new treatment paradigm in
their EMS system. ✚
Karl B. Kern, MD, is a professor of Medicine at the University of Arizona. He’s also the Gordon A. Ewy, MD, Distinguished Endowed Chair of Cardiovascular Medicine
and is co-director of the Sarver Heart Center. He may be
contacted at firstname.lastname@example.org.
1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and
stroke statistics—2016 update: A report from the American
Heart Association. Circulation. 2016;133( 4):231–241.
2. Nichol G, Thomas E, Callaway CW, et al. Regional variation in
out-of-hospital cardiac arrest incidence and outcome. JAMA.
2008;300( 12):1423–1431. [Published correction appears in
JAMA. 2008;300( 15):1763.]
3. Stiell IG, Wells GA, Hebert PC, et al. Association of drug therapy
with survival in cardiac arrest: Limited role of advanced cardiac
life support drugs. Acad Emerg Med. 1995; 2( 4):264–273.
4. Narcotics Anonymous: The basic text of narcotics anonymous,
6th edition. Narcotics Anonymous World Services: Chatsworth,
Calif., p. 24, 2008.
5. Böttiger BW, Arntz HR, Chamberlain DA, et al. Thrombolysis
during resuscitation for out-of-hospital cardiac arrest. N Engl J
Med. 2008;359( 25):2651–2662.
6. Rubertsson S, Lindgren E, Smekal D, et al. Mechanical chest
compressions and simultaneous defibrillation vs. conventional
cardiopulmonary resuscitation in out-of-hospital cardiac arrest:
The LINC randomized trial. JAMA. 2014;311( 1):53–61.
7. Wik L, Olsen JA, Persee D, et al. Manual vs. integrated automatic load-distributing band CPR with equal survival after
out-of-hospital cardiac arrest. The randomized CIRC trial.
Resuscitation. 2014;85( 6):741–748.
8. Brooks SC, Anderson ML, Bruder E, et al. Part 6: Alternative
techniques and ancillary devices for cardiopulmonary resuscitation: 2015 CPR American Heart Association guidelines update
for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132 ( 18 Suppl 2):S436–S443.
9. Becker LR, Zaloshnja E, Levick N, et al. Relative risk of injury and
death in ambulances and other emergency vehicles. Accid Anal
Prev. 2003;35( 6):941–948.
10. Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal ambulance crashes in the United States: An 11-year retrospective
analysis. Prehosp Emerg Care. 2001; 5( 3):261–269.
11. Sunde K, Wik L, Steen PA. Quality of mechanical, manual standard and active compression-decompression CPR on the arrest
site and during transport in a manikin model. Resuscitation.
12. Olasveengen TM, Wik L, Steen PA. Quality of cardiopulmonary
resuscitation before and during transport in out-of-hospital cardiac arrest. Resuscitation. 2008;76( 2):185–190.
13. Nagao K, Kikushima K, Watanabe K, et al. Early induction of
hypothermia during cardiac arrest improves neurological outcomes in patients with out-of-hospital cardiac arrest who
undergo emergency cardiopulmonary bypass and percutaneous
coronary intervention. Circ J. 2010;74( 1):77–85.
14. Belohlavek J, Kucera K, Jarkovsky J, et al. Hyperinvasive
approach to out-of hospital cardiac arrest using mechanical chest compression device, prehospital intraarrest cooling,
extracorporeal life support and early invasive assessment compared to standard of care. A randomized parallel groups comparative study proposal. “Prague OHCA study.” J Transl Med.
15. Siao F Y, Chiu CC, Chiu CW, et al. Managing cardiac arrest
with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus
extracorporeal cardiopulmonary resuscitation. Resuscitation.
16. Reynolds JC, Frisch A, Rittenberger JC, et al. Duration of resuscitation efforts and functional outcome after out-of-hospital
cardiac arrest: When should we change to novel therapies?
Circulation. 2013;128( 23):2488–2494.
17. Yannopoulos D, Bartos JA, Martin C, et al. Minnesota resuscitation consortium’s advanced perfusion and reperfusion cardiac
life support strategy for out-of-hospital refractory ventricular
fibrillation. J Am Heart Assoc. 2016; 5( 6):e003732.
18. Rab T, Kern KB, Tamis-Holland JE, et al. Cardiac arrest: A
treatment algorithm for emergent invasive cardiac procedures in the resuscitated comatose patient. JAm Coll Cardiol.
19. TandemLife Kit. (2017.) TandemLife. Retrieved Oct. 17, 2017,
20. Yannopoulos D, Bartos JA, Raveendran G, et al. Coronary artery disease in patients with out-of-hospital refractory ventricular fibrillation cardiac arrest. J Am Coll Cardiol.
21. Kern KB, Hilwig RW, Rhee KH, et al. Myocardial dysfunction
after resuscitation from cardiac arrest: An example of global
myocardial stunning. J Am Coll Cardiol. 1996; 28( 1):232-240.
22. Kern KB, Hilwig RW, Berg RA, et al. Post-resuscitation left ventricular systolic and diastolic dysfunction: Treatment with dobu-tamine. Circulation. 1997;95( 12):2610–2613.
23. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest
treated with mechanical CPR, hypothermia, ECMO and early
reperfusion (the CHEER trial). Resuscitation. 2015;86:88–94.