ECMO at the Louvre, two art forms meet. We first tweeted this photo back in 2014, and now the case report behind the image has just been published. The case report highlights both the possibilities of new frontiers in medicine, as well as their shortcomings. These high-tech interventions come at a cost, and could end up just complicating things without saving lives. Classic sexy way of wasting money. Or, with the right patient selection, it could save lives.
The lines at the Louvre
The case is classic cardiac arrest, just in a spectacular location: a tourist collapsing inside the Louvre. The big museum and the big crowds posed a big challenge to the medical response crew. Even though they’re in central Paris, and the ECLS was called 10 mins after starting CPR, the ECMO crew arrives at the patient and initiates cannulation 67 mins after arrest. ECMO is up and running 90 minutes after arrest.
90 minutes is probably too long in low-flow state, and even though the patient’s initial rhythm was VF, the pt was in asystole when the medical crew arrived. The patient died in hospital 24 hours after admission. For a pre-hospital ECMO success story, look at this one. But overall, pre-hospital ECMO initiation hasn’t yielded great results.
Prehospital ECMO is a heroic intervention, and once initiated, it’s hard to stand down, despite delays enroute. But as the case report mentions, patient selection is critical, and limiting low-flow time is one of the critical components for good outcome. The case report also mentions several other pre-hospital ECMO cases, but do not mention their outcomes. There is the Prague OHCA study underway in the Czech Republic, and London HEMS is rumoured to be starting pre-hospital ECMO as well. So, we’ll probably have more data soon, and arrest-to-ECMO will be the new door-to-balloon criteria for both pre-hosp and in-hosp ECMO centers.
And the discussion will continue on where to draw the line on ECMO initiation in cardiac arrest. Everything points to a rather restrictive policy is the way to go: Witnessed arrest, bystander/immediate CPR initiation with good compressions, an age/comorbidity criterium, and a max time to return of circulation (ROC) by ECMO, and ~60 minutes is probably a reasonable max time cut-off, weighing feasability against survival chances. Another approach is to look at pulling out early and wean ECMO in lost cases – typically within 24-48 hours. It will be interesting to follow.