hospital for ECPR implementation), the
main reason found for these poor resuscitation results was the prolonged low-flow time
period (between initiation of cardiac massage
and ECPR pump flow). 5
We found that one of the items contributing to this low flow period was extraction
and transportation times to the hospital after
failure of ALS to obtain ROSC. Indeed, in
urban settings around the world, it’s often
difficult for patients to be treated in the hospital within 45–60 minutes of cardiac arrest,
even with a load and go strategy. 6, 7
To begin implementation much
earlier, we decided to design a system where ECMO is available as a
second line of treatment by a team
equipped to treat the patient on
scene (e.g., in the street, in the
metro, in an apartment, etc.).
The ECPR program at the
SAMU de Paris was established
in 2011.9, 10 Physicians were initially trained for percutaneous
implementation, but progressively
switched to the surgical hybrid
technique due to difficulties with implementing ongoing cardiac massage.
The ECPR team was initially alerted and
put on standby in cases of witnessed OHCA
for patients under the age of 70, and the team
could be requested after 10 minutes of unsuccessful ALS by the MoICU team.
Since 2015, the ECPR team has been available 24/7. The ECPR team is systematically
dispatched immediately when a call comes in
for witnessed cardiac arrest, at the same time
as the BLS unit and MoICU. This is done to
be able to start ECPR implementation early,
after just 20 min of CPR with an AED, as
recent studies have shown that 20 minutes
seems to be the optimal time to switch from
conventional CPR to ECPR. The team is
secondarily canceled if ROSC occurs during
ALS or if there’s no indication for ECPR.
The ECPR unit can also be requested by
the MoICU doctor for patients where chest
pain advances into cardiac arrest. The objective behind early dispatch and implementation is to activate the ECMO pump within
60 minutes of collapse.
During 2015, prehospital ECPR implementation was the default strategy, except if
the cardiac arrest occurred in the ambulance
or with a very short extraction and transport
time allowing for in-hospital implementation.
The ECPR team can also be requested
by the SAMU dispatch centers from other
departments surrounding Paris. This requires
a very early alert in order to organize and dispatch the team, especially if this requires the
team to be sent out by helicopter.
With this strategy, patients previously too
far to reach an ECPR center have become eligible, thus allowing greater equity of care. In
this situation, the ideal low-flow time of 60
minutes is extended to 90 minutes.
STAFFING & PROTOCOLS
The mobile ECPR response team is available
24/7 and is staffed by three people: a physician
(anesthetist-intensivist or emergency physician), an anesthetic nurse and a paramedic.
The physician is responsible for implementing ECPR according to SAMU’s hybrid surgi-cal/Seldinger technique, assisted under “sterile”
conditions by the first on-scene MoICU doctor first or another available assistant.
The anesthetic nurse is responsible for priming the ECMO machine during the implementation and then preparing necessary drugs
with the help of the nurse from the MoICU.
(Vasoactive drugs and sedation are systematically administered after ECPR initiation.)
The paramedic assists the physician during
implementation, retrieving and handing the
necessary equipment under sterile conditions.
Once the ECMO pump has been initiated
and pump flow is satisfactory, the patient is
transported to the hospital under strict monitoring and supervision, with the team paying
close attention to the cannula, circuit, machine
and operational and clinical parameters.
Before and during implementation, the
ECPR physician coordinates information concerning patient extraction, ensuring acceptable
mobilization positions for the patient, especially in case of difficult extraction.
Special protocols have been written to
ensure the ECPR process flows at every level.
Call center protocol: A protocol exists in two
parts. The first protocol dictates the dispatching of the ECPR team in the case of witnessed
OHCA for patients under the age of 70 and
A second protocol guides the steps once
the indication of ECPR has been confirmed.
In this case, one person in the dispatch center is dedicated to this case until the patient
reaches the hospital.
This protocol includes coordination with other services: firefighters in charge of the BLS;
police to escort the ECPR team;
blood bank staff in cases where
prehospital transfusion is needed,
or where ICU or coronary angiography are indicated. All of these
steps are checked and followed in
On-scene protocols: Two protocols exist. One for the ECPR team,
When SAMU dispatch centers outside of
Paris request ECPR, the protocol ensures that
the Paris ECPR response unit is dispatched
early so that the team arrives on scene with
RESULTS & NEXT STEPS
The prehospital ECPR response team follows
a scientific program. The first phase was the
publication of the safety and feasibility. The
second phase of the research was published
more recently, including comparing a series of
patients during two successive periods.
As described previously, from 2011–2014,
the ECPR team was sent out in the absence
of ROSC after 10 min of ALS.
In 2015, the ECPR team was sent out at
the same time as the MoICU, in order for the
team to be on the scene as soon as possible
and be able to initiate ECPR early in case of
absence of ROSC after 20 minutes of professional CPR. The objective was to reduce the
low flow period, which is clearly a prognostic
factor for neurological outcome.
Patients eligible for ECPR were: witnessed
Results from implementing
on-scene ECMO show an
increase in survival rate from
8–29% with acceptable