“If you can put in a central line or a dialysis catheter, you can place a patient on ECMO”

– Dr. Zach Shinar

We have discussed ECMO-CPR, or ECLS, earlier. Those papers were on in-hospital cardiac arrests. Here’s a real world account from Sharp Memorial Hospital in San Diego where they use ECMO-CPR on out of hospital cardiac arrests if they meet the inclusion/exclusion criteria. And with good results.

Out of 9 people put on emergency V-A ECMO at the Sharp Memorial the last 18 months, 4 have left the hospital neurologically intact.

These 9 were patients were no other resuscitation effort worked. It’s easy to work out the survival rate of the control group. Small, but impressive numbers. And this was ECMO initiated in the ED, by emergency physicians and the ECMO pump run by a ED nurse specially trained in keeping the ECMO up and running until the perfusionists get to the hospital.

Dr. Swandon of the excellent EM:Rap blog did an interview with Dr. Shinar who works at Sharp Memorial ED: “You don’t have time to wait for the whole perfusion team. This is emergency ECMO by emergency doctors and nurses.”

Dr. Shinar believes that getting an ECMO machine up and running on a critical patient isn’t as complicated as one might think. Apparently, even emergency docs can do it. The important thing is to have the necessary back-up services close at hand to take patients to definitive therapy.

Image from the Emergency Physicians Monthly article

“If you can put in a central line or a dialysis catheter, you can place a patient on ECMO.” It might be that simple to get the ECMO lines in, but you’ll need a little more than that to be able to get the ECMO circuit up and running and to be able to trouble-shoot common problems. But I agree: ECMO sounds a lot more fancy and complicated than it really is. Basically, V-A ECMO is a rotary pump that sucks blood out of the patient’s vena cava, pumps it over a gas exchange membrane and then back into the patients aorta. It’s just a rotary pump with an oxygenator. The ECMO machines even have a back-up hand crank that lets you circulate the blood manually if needed.

So, it should be possible to get a patient started on rescue ECMO in a non-specialised hospital, provided you have a destination. Definitive therapy is a key step here. ECMO doesn’t save any one – it buys time. You need to have an exit strategy even before switching on that ECMO pump. So you need to adhere to strict inclusion/exclusion criteria. Emergency ECMO is not for every patient.

Here’s the short version of Sharp Memorial’s protocol for ED ECMO:

Inclusion Criteria
•Persistent cardiopulmonary arrest despite traditional resuscitative efforts
•Shock (SBP<70 mmHg) refractory to standard therapies Exclusion Criteria
•Initial rhythm asystole
•Chest compresions not initiated within 10 min of arrest (either bystander or EMS personnel)
•Estimated EMS transport time > 10 min
•Total arrest time > 60 min
•Suspicion of shock due to sepsis or hemorrhage
•Pre-existing sever neurological disease prior to arrest (including traumatic brain injury, stroke, or severe dementia)

Dr. Swadron echoes my thoughts on this: “The ethical dimensions of all of this are enormous. In fact, we worried a little bit about running the [Dr. Shinar] interview on EM:RAP because we felt that many in our audience would think this is a bit unrealistic and raises the bar too high. But upon reflection, this is precisely where our specialty is heading: aggressive reanimation of those patients that still have a meaningful quality of life ahead of them. How this technology is applied is going to be controversial, but if we don’t forge the way ourselves, others may take the initiative from us.”

I’ve been thinking the same thing. I see a huge potential for ECMO, also in out-of-hospital critical care patients coming into our ED’s. Acute, severe, but reversable lung or heart failure can be effectively managed with ECMO. But I’ve been a little uncomfortable saying it out loud. Afraid to be seen as disconnencted and unrealistic. On the other hand, medicine would’ve gotten nowhere without people believing in new treatments and pushing to get them into service. With the new, simpler to use machines and the improved heparin coated ciruits that takes away the need for full heparinisation and the bleeding complications that follows, ECMO seems ready for prime time. Cardiac arrest is the most extreme form of acute, severe and often reversible heart failure. The patient needs to have his circulation restored immediately to save vital organs, especially the brain. ECMO does that. ECMO buys you time. Time to figure out the definitive treatment, and time to get the patient there.

I’ve seen enough young patients in cardiac arrest die because we couldn’t get them to stay in a viable rythm, or even if they got to the PCI lab and got the occlusion open, the (reversible) heart stunning was so bad they didn’t survive. With a little help from V-A ECMO, these people could’ve been helped through the acute setting until their own heart was ready to take over.

So go read the article and listen to the interview. Intense stuff.

Bypass the OR: ECMO in the ED

All I can say is that I want a service like that in my hospital.

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