Figure 2: 12-lead ECG of 52-year-old male displaying sinus arrhythmia with frequent multiform PVCs
CARC at the time of resuscitation, especially for
use in refractory OHCA.
This particular SRC/CARC is very familiar with
aggressive resuscitation strategies—two cardiac
arrest patients had been taken to the catheterization lab with active mechanical CPR that same
year, both of which survived with good neurologic function.
The 2015 AHA Guidelines state that there’s
insufficient evidence to recommend the routine
use of ECPR in cardiac arrest; however, ECPR may
be considered for select patients for whom the suspected etiology of the cardiac arrest is potentially
reversible (e.g., patients experiencing refractory
cardiopulmonary arrest/OHCA) during a limited
period of mechanical cardiorespiratory support.
Published series have used rigorous inclusion
and exclusion criteria to select patients for ECPR.
Although these inclusion criteria are highly variable,
most included only patients aged 18 to 75 years, with
arrest of cardiac origin, after conventional CPR for
more than 10 minutes without ROSC. Such inclusion criteria should be considered in a provider’s
selection of potential candidates for ECPR.
Two recent studies each demonstrated sur-vival-to-hospital discharge greater than 50% with
good neurologic function for patients experiencing refractory in-hospital cardiac arrest (IHCA) as
well as OHCA with the use of ECPR. 20, 21
From Concept to Practice
In the fourth quarter of 2016, only a few months
Despite a slight decrease in overall survival (10%)
after first discussion with ALCO’s SRC/CARC
stakeholders regarding the concept of using
mechanical CPR as a bridge to ECMO, one cen-
ter had their first opportunity to utilize the ECMO
option and they did with amazing success!
Oakland Fire Department and Paramedics Plus
(Alameda County’s largest contracted EMS ambu-
lance transport provider) were dispatched code 3
utilization of prehospital ITD and mechanical
chest compression, as well as in-hospital percuta-
neous coronary intervention (PCI) and targeted
and v fib/v tach survival (27%) from recent years
past, the 2016 data reflects the highest overall
ROSC rate for the system in the past decade (37%).
And from those patients admitted that survived
to hospital discharge, the mass majority (75%) were
neurologically intact and an even higher number
(89%) for both witnessed and unwitnessed v fib/
v tach. (See Figure 1, p. 29.)
At ALCO SRC/CARC meeting in the second quarter of 2016, shortly after the release of the 2015
AHA Guidelines, the topic of extracorporeal CPR
(ECPR) using an extracorporeal membrane oxygenation (ECMO) device for patients experiencing
refractory cardiopulmonary arrest (CPA) including
OHCA was presented by EMS leadership.
This presentation was prompted by the case of
a 15-year-old male that was a witnessed OHCA,
received bystander CPR and was found in v fib by
EMS on their arrival. Initial ACLS was delivered
by EMS according to ALCO-prescribed prehospital protocol and the patient was transported to
the nearest SRC/CARC in a shock refractory state.
On arrival at the receiving center, the patient
received an additional 90 minutes of gallant and
innovative resuscitative effort by the ED staff 120
minutes before the patient was pronounced dead.
With collaborative review of this case, it was clear
that the SRC/CARC had no other care in our existing protocol to offer the patient or family by the
end of the resuscitation. The only ECMO-capable
hospital in Alameda County, currently and at the
time of this case, was the local Children’s Hospital. ECMO wasn’t considered by the adult SRC/