Out-of-hospital cardiac arrest (OHCA) remains a major cause of mortality for which we rely on advanced cardiac life support (ACLS) guidelines to manage within the ED. However, when these guidelines fail, we are left with almost no additional options as lifesaving measures. Worldwide there has been exponential growth in the use of veno-arterial extracorporeal membranous oxygenation (VA ECMO) – a bedside heart-lung bypass modality – in order to take control of the physiology of patients in cardiac arrest in order to perform additional life-saving interventions.
What is ECMO?
VA ECMO consists of three major components:
- A pump (below left) using either a rotary or centrifugal motor
- An oxygenator (below top right, red arrow)
- An arterial and venous cannula (below bottom right)
This system is also very lightweight and portable. Sufficiently so, that it is currently being used for pre-hospital and inter-hospital transport via both land and air ambulance (below left).
As you can imagine, it is extraordinarily difficult to perform a randomized controlled trial (RCT) on ECMO based on the low frequency of its use in OHCA and very high mortality of patients if it is not instituted. Multiple case reports, case series and observational trials have demonstrated efficacy of ECMO for OHCA.
Interestingly, following the initiation of their ED ECMO program for OHCA at Sharp Memorial Hospital in San Diego, they increased the survival of their OHCA from 13% in 2010 to 28% in 2014. This is, however, completely disregarding the number of ECMO patients.
- ‘Pit-Crew CPR’ (Hopkins et al., 2016; Prince, Hines, Chyou, &Heegeman, 2014)
- RN-led codes (Gilligan et al., 2005)
- Mechanical CPR devices (Perkins, Lall, Quinn, & Deakin, 2015)
- Insertion of femoral venous and arterial lines in every OHCA
- ED MD’s, RN’s, RT’s, Porters, Clerks, etc
- Cardiac Surgery ICU
- Cardiac Anesthesia
- Cardiothoracic Surgery
- Hospital Administration
- Resource intensive
- Real-estate (where do the patient’s go once on ECMO)
- Availability of CV surgery OR’s