outside of what are currently rather local catchment areas. The interfacility transport of patients
on a pump is already a reality in some areas.
The Future of ECPR
ECPR is a promising area of advanced resuscitation science that’s enjoying a renaissance in the
treatment of OHCA and other, often fatal, conditions. Prehospital providers will play a critical
part of the continuum of care, just as in STEMI,
stroke and trauma.
Although ECPR is an exciting rescue therapy,
outcomes will only be optimal in systems that
provide high-quality and minimally interrupted
chest compressions in all cases, including those
that go on to require ECLS. ✚
Sean Slack, DO, is currently third-year emergency medicine resident at the University of Utah School of Medicine.
Hill Stoecklein, MD, is a clinical instructor at the University of Utah School of Medicine and associate medical
director with the Salt Lake City Fire Department.
Joseph E. Tonna, MD, FAAEM, is an emergency physician and cardiovascular intensivist at the University of
Utah School of Medicine. He’s also the associate director
of ECMO. Contact him at firstname.lastname@example.org.
Scott T. Youngquist, MD, MS, FAEMS, FAHA, is associate professor of emergency medicine at the University
of Utah School of Medicine and medical director for the
Salt Lake City Fire Department. He may be contacted at
1. Forrester JS. The heart healers:The misfits, mavericks, and rebels
who created the greatest medical breakthrough of our lives.
St. Martin’s Press: New York, p 76, 2015.
2. Rubertsson S, Grenvik A, Zemgulis V, et al. Systemic perfusion
pressure and blood flow before and after administration of
epinephrine during experimental cardiopulmonary resuscitation. Crit Care Med. 1995; 23( 12):1984–1986.
3. Ortega-Deballon I, Hornby L, Shemie SD, et al. Extracorporeal
resuscitation for refractory out-of-hospital cardiac arrest in
adults: A systematic review of international practices and outcomes. Resuscitation. 2016;101: 12–20.
4. Maekawa K, Tanno K, Hase M, et al. Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac
arrest of cardiac origin: Propensity-matched study and predictor analysis. Crit Care Med. 2013;41( 5):1186–1196.
5. 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.
6. 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.
Once access is established and appropriate positioning confirmed by ultrasound, a series of dilators are successively inserted allowing insertion of
large bore ( 15-27 French) cannula that can support the high volume, pressure and flow rates of
the ECMO system.
Once the cannula is in place, the machine must
be primed and the patient anticoagulated to minimize the risk of clots. When a suitable flow rate
has been confirmed, CPR is discontinued.
These patients are then taken emergently to the
cardiac catheterization lab for angiography and
possible percutaneous intervention (PCI) in the
same fashion as victims with ST-elevation myocardial infarction (STEMI). Cooling and rewarming,
along with weaning from ECMO and neurologic
prognostication occur over the next several days.
See Figure 2, p. 21, for results to date using ED
ECMO alerts for OHCA..
ECLS seems likely to benefit a select group of
patients that require temporary heart/lung support until definitive therapy can be achieved.
However, the lack of randomized trials and the
heterogeneous nature of case series create uncertainty regarding selection criteria. (See Table 2 for
the University of Utah ECLS selection criteria.)
Prehospital protocols should employ criteria
broad enough to account for the information-poor environment in which EMS operates, where
obtaining a detailed history of the patient’s prearrest health status can be challenging while still
avoiding the overtriage and transport of clearly
Furthermore, protocols requiring the transport
of OHCA victims for potential ECLS therapy
must carefully consider the risks of transporting
victims during arrest, including the considerable
potential for interruptions in the continuity and
quality of chest compressions and safety risks to
Therefore, mechanical chest compression
devices are probably a necessary component of
any field-to-hospital ECPR strategy that aims to
Additionally, the time to transition from traditional methods of resuscitation to ECPR is also
uncertain. Should crews spend five, 10, 15 or 20
minutes attempting field resuscitation before initiating transport? How far and long should crews
travel to reach ECPR-capable facilities?
ECPR programs are likely to be found in tertiary
care centers at this time, although the portabil-ity of ECPR units may enable a hub-and-spoke
type system in the future, extending any benefits