JACEP Open Podcast: Out‐of‐hospital extracorporeal membrane oxygenation

Many emergency medical services (EMS) medical directors are faced with challenging clinical decisions, including when to transport a patient undergoing cardiopulmonary resuscitation (CPR). This can be dangerous for the EMS crew and usually has a poor outcome for the patient. This month, we review a case study in JACEP Open by Dr. John Marinaro and colleagues of a resuscitation in Albuquerque, New Mexico, in which extracorporeal membrane oxygenation (ECMO), or E‐CPR, was started in the field. Out‐of‐hospital ECMO has been done in other countries, notably in the Paris, France EMS system. This is the first case report of a US case, however. Prior case series have shown promising results with the usual caveats associated with case series. This case report describes a procedure that might give EMS medical directors an additional tool for out‐of‐hospital cardiac arrest.

The out‐of‐hospital response team developed in Albuquerque is a partnership between the University of New Mexico (UNM) College of Medicine and Albuquerque Fire Rescue (AFR). It consists of 2 emergency physicians, an EMS physician, and Albuquerque fire fighters who served as trained surgical assistants. The Albuquerque Fire Department retrofitted one of their reserve ambulances (code named “ECMO 1”) specifically for ECMO. One novel feature of this ambulance is the ability to “reverse load” patients with their head nearest the rear door, opposite of traditional loading. This allows the cannulation physicians access to the patient's groin inside the unit while paramedics maintain access to the patient's head in order to run the ongoing resuscitation from outside the ambulance.

ECMO‐1 and the associated physician response are scarce commodities and, obviously, cannot be sent to every cardiac arrest. Therefore, explicit criteria are in place to best target the response to those most likely to benefit. The following criteria are used for deployment of ECMO:

• 18–75 years of age

• Witnessed arrest (under 5 minutes between cardiac arrest and initiation of CPR)

• Less than 60 minutes total until ECMO‐enhanced flow is established

• Non‐asystolic initial rhythm

• No end‐stage or terminal comorbidities

• Anticipated cardiac arrest to hospital arrival greater than 35 minutes

ECMO‐1 is kept in a station near UNM Hospital. When dispatch criteria are confirmed, AFR personnel respond to the hospital to pick up the ECMO team who then rendezvous with other EMS personnel already on scene. Both ECMO‐1 and traditional EMS units, including the EMS physician, are simultaneously dispatched to avoid response delays. At any point in the response ECMO‐1 is cancelled as soon as on‐scene crews determine the patient does not meet inclusion criteria.

On‐scene EMS personnel provide initial resuscitation. If there is no early return of spontaneous circulation, the patient is packaged and moved to the street in preparation for the arrival of ECMO‐1. The patient is loaded, and cannulation is performed inside ECMO‐1. A covered tent is set up at the back of the ambulance to extend the working surface and protect against rain or snow. Once on pump, the patient is transported without lights and sirens to the emergency department for definitive care.

At the time of this podcast there have been 4 cases performed in the City of Albuquerque. Unfortunately, none of the patients survived to discharge; however, 2 of the patients became organ donors. Additionally, these cases have given the team experience with this procedure in a unique environment. The technical aspects of the procedure seem to be working well. As this procedure is refined in the City of Albuquerque, it may offer progressive EMS services another avenue to increase survival to discharge numbers for cardiac arrest patients.

King T, Barajas B, Jarvis JL. JACEP Open Podcast: Out‐of‐hospital extracorporeal membrane oxygenation. JACEP Open. 2020;1:474–475. 10.1002/emp2.12216