The Centers for Disease Control and Prevention (CDC) notes that every year more than 365,000 people in the United States will experience an out-of-hospital cardiac arrest.1 However, even in cases where quick-thinking bystanders skillfully administer cardiopulmonary resuscitation (CPR) before paramedics arrive to take over, the odds of surviving a cardiac arrest are bleak. Data suggest well more than half of patients experiencing an out-of-hospital cardiac arrest are likely to die before they make it to the hospital.2
But what if there was a way to improve the odds of survival in such cases? In fact, evidence is growing that for a subset of patients experiencing cardiac arrest — those with a shockable rhythm, for starters — a technique referred to as extracorporeal cardiopulmonary resuscitation, or ECPR, not only is making survival from cardiac arrest possible, but many of the patients treated with ECPR are able to walk out of the hospital and resume their lives with no lasting neurological or physical damage.3,4
However, providing a patient with ECPR is hardly a simple matter. It essentially involves placing the patient on an extracorporeal membrane oxygenation (ECMO) machine to take over the work of the heart and lungs and to maintain perfusion to the brain. It requires a highly skilled clinician capable of quickly performing the delicate task of connecting a patient’s heart and lungs to an ECMO device without causing further damage, such as perforating a vein or an artery, in the process. Further, after a patient is placed on an ECMO machine, he or she requires specialized, intensive care unit (ICU)-level care.
While an ECPR program requires considerable resources, training, and — ideally — regional coordination, some health systems and communities are working together to make ECPR available to their populations. Further, in some cases, emergency medicine providers are playing a leading role — not just in the care of these patients, but also in the effort to make this novel technique more widely available.
For instance, encouraged by the results of a collaborative effort in Los Angeles to make ECPR available to patients in that region, healthcare leaders in San Diego were determined to put together a program for their community.3 This prompted the San Diego County Emergency Medical Services (EMS) office to establish the San Diego Resuscitation Consortium Workgroup and to explore the feasibility of operationalizing an ECPR program.
Following the creation and approval of EMS treatment protocols, San Diego’s ECPR Pilot Program officially debuted on July 1, 2023, with three hospitals in the region approved to receive patients eligible for ECPR: Sharp Memorial Hospital in San Diego, Sharp Grossmont Hospital in La Mesa, and Scripps Memorial Hospital in La Jolla.
“The model that we are moving forward with here in San Diego County is we’re training a lot of emergency physicians on how to do [ECPR], and then [coupling that] with specialized staff,” explains Chris Stirk, MSN, RN, who was tapped to be the ECMO coordinator at Sharp Grossmont Hospital in 2021. He notes that highly trained clinicians are needed to care for patients after they have been connected to the powerful ECMO devices. (See “An Alternative Model to ECPR: Keeping the Pool of Physicians Skilled in the Procedure Small.”)
Stirk acknowledges that the process of performing ECPR is highly complicated. “We’re putting someone in cardiac arrest on a heart-lung bypass machine in less than an hour in the ED,” he says. “That is pretty amazing, but, technically, that’s the easy part.”
The patient’s trajectory during their hospital stay is much more challenging — especially if he or she is going to be able to make it to discharge with good neurological function — but at the same time, it is the most rewarding thing, states Stirk.
“When most of the doctors, nurses, and techs in the ED see a patient in cardiac arrest, they see them at their worst,” he explains. “So one of the best things we have been able to do here is when patients are doing well and feeling better, I will either bring some of the ED staff [who] worked on the patients up to meet them in their rooms or I will put the patients in a wheelchair and bring them down to visit the ED. That’s probably the most fun.”
Of course, getting to the point of being able to offer ECPR requires a big investment in training and resources, states Stirk. He notes that most of the emergency physicians capable of performing ECPR at his hospital have learned the technique at Reanimate, a yearly conference in the region that is focused entirely on ECMO and ECPR. (https://reanimateconference.com/)
However, nurses also require training to assist physicians performing ECPR, explains Stirk. “We started off by giving about 16 hours of ECMO and ECPR training to 24 ICU nurses to build as a foundation [for the ECPR program], and then we trained 24 of the ED nurses on the process as well,” he explains. “Also, every quarter, we bring the nurses in for two hours to review on initiating the ECMO machine, assisting the physician, and the process itself.”
Another critical component of the San Diego pilot that Stirk has been involved with is training for prehospital providers. He notes that paramedics need to identify patients who are candidates for ECPR and then ensure that these patients are taken to one of the three receiving hospitals that offer ECPR as quickly as possible.
The inclusion criteria for ECPR are:
• a shockable rhythm is identified;
• the patient is 18-70 years of age;
• the case involves a witnessed arrest;
• there must have been bystander CPR;
• patients need to arrive at the hospital within 45 minutes of arrest.
Stirk states that about 40 emergency and ICU physicians from Sharp Grossmont have undergone the training needed to perform ECPR, enabling the hospital to offer the procedure to eligible patients at any time.
In addition to patients experiencing out-of-hospital cardiac arrest, there are times when inpatients go into cardiac arrest and meet the criteria to receive ECPR. In such cases, an ECPR-trained emergency physician may be called to respond.
In 2023, a total of 22 patients received ECPR at Sharp Grossmont Hospital; this includes 10 patients who received the procedure in the ED, notes Stirk. “We’ve had seven survivors who got discharged with good neurological outcomes,” he says. “That might not sound like a lot, but these are patients who would not have survived [without ECPR].”
While offering ECPR is relatively new to Sharp Grossmont Hospital, a sister facility, Sharp Memorial, has been performing ECPR for years, explains Mary Scarlett, ACNP, manager of the ECMO program there. “Our first ECPR case was in 2010,” she says, noting that EMS picked the patient up and brought him to the hospital in cardiac arrest. “They put him on ECMO; then he had interventions done and he survived and went on to talk about it in the community.”
Scarlett explains that the emergency physician who worked on this patient on his arrival at Sharp Memorial was Zachary Shinar, MD, who is now highly involved nationally and internationally with ECPR and ECMO. Further, Shinar is the course director for Reanimate, the annual conference in the region to train physicians on ECPR and ECMO.
Although Sharp Memorial has years of experience with ECPR, the San Diego pilot presented a big opportunity to expand the hospital’s mission, explains Scarlett. “One of the things I really wanted to do was work hard to improve our outcomes with ECMO and really expand some of our programs into other fields, such as bridging patients to transplant, bridging patients to LVADs (left ventricular assist devices), and those types of things,” she says. “Because we have those options [here at the hospital], ECMO is a good stepping stone to get somebody to a successful outcome.”
When EMS notifies the hospital that a potential ECPR candidate is coming, a “code ECMO” is called, states Scarlett. “My ECMO team responds to that code by going to the emergency department to contribute to the process of putting the patient on ECMO,” she says.
When the patient arrives, the ECMO team works with the emergency physician to go through the inclusion criteria to make sure the patient is eligible for ECPR, and they do some initial blood tests, shares Scarlett.
Currently, Sharp Memorial has 38 emergency physicians trained to cannulate, states Scarlett. “They put a venous cannula in the femoral vein and an arterial cannula in the femoral artery,” she says. “This is called peripheral ECMO because there are different ways that you can cannulate patients for ECMO, but this is how we do it for ECPR.”
Scarlett further clarifies that the type of ECMO used for ECPR is veno-arterial ECMO, which is used to support the lungs and the heart. This differs from the type of ECMO that was commonly used during the COVID-19 pandemic. That was veno-venous ECMO, which is used to support the lungs, she explains.
Having such a large number of clinicians equipped to do ECPR means the hospital is ready at any time to perform the procedure on patients who arrive at the ED in cardiac arrest. Scarlett notes that in 2023, the hospital had 34 cases involving ECPR, with a survival rate of 39.3%. In 2024, as of mid-April, the hospital had provided ECPR to 10 patients with a survival rate of 50%, she says.
While some pioneering ECPR programs rely on specialists other than emergency physicians to initiate ECPR, Scarlett believes that developers of the San Diego model made a good call in delegating the task to emergency physicians. “If you had to wait for a cardiac surgeon or a cardiologist to get to the hospital to do this, that would delay care,” she says. “The fact that emergency physicians here can do this and do it well is really a great asset.”
REFERENCES
- Benjamin EJ, Virani SS, Callaway CW, et al. Heart Disease and Stroke Statistics – 2018 Update: A Report from the American Heart Association. Circulation 2018;137:e67-492.
- Tsao CW, Aday AW, Almarzooq ZI, et al. Heart Disease and Stroke Statistics – 2023 Update: A Report from the American Heart Association. Circulation 2023;147:e93-621.
- Suverein MM, Delnoij TSR, Lorusso R, et al. Early extracorporeal CPR for refractory out-of-hospital cardiac arrest. N Engl J Med 2023;388:299-309.
- Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): A phase 2, single centre, open-label, randomized controlled trial. Lancet 2020;396:1807-1816.
The Centers for Disease Control and Prevention notes that every year more than 365,000 people in the United States will experience an out-of-hospital cardiac arrest. However, even in cases where quick-thinking bystanders skillfully administer cardiopulmonary resuscitation before paramedics arrive to take over, the odds of surviving a cardiac arrest are bleak. But what if there was a way to improve the odds of survival in such cases?
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