- Scope
- 2) Out of hospital cardiac arrest survival: ACLS vs ECPR (data/trials). 3) Inclusion/Exclusion and protocols. 4) Published experiences & prerequisites. 5) Short cases.
- Key Definitions
- ECLS: extracorporeal cardiopulmonary life support.
- ECPR: initiation of ECMO flows during CPR.
- Sudden cardiac arrest: sudden cessation of blood flow not from terminal stages of another illness.
- Why beyond ACLS
- Doing the same (high quality CPR, intubate, epi, bicarb, shocks) → survival did not meaningfully change.
- Additional tools: resuscitative TEE, beta blockers for VT storm, intra balloon pumps, thoracotomies, ECPR.
- Evidence Highlights
- ROC data: wide survival range; day vs night; monitored vs unmonitored.
- AHA 2021: adult EMS treated non-traumatic out of hospital cardiac arrest survival 1%.
- PARAMEDIC2: favorable neurological outcome 8%.
- ARREST (Minnesota): ECPR 43% vs ACLS 7%; CPC ≈ 1; mobile ECMO survival 43%.
- PRAGUE/INCEPTION: issues (crossover, cannulation, experience); signal toward benefit.
- Systematic review/meta-analysis: ECPR favored survival and favorable neurological outcomes.
- Number needed to treat: ECPR 5 vs ACLS 33.
- Inclusion (core)
- Age <70, witnessed arrest, no-flow <5 min, low-flow <60 min, initial VT/VF (± selected PEA), EtCO₂ >10.
- Override: signs of life during CPR.
- Exclusion
- Hard: life-limiting comorbidities, no-flow >5 min, significant aortic insufficiency.
- Soft: low-flow >60 min, pH <6.8, lactate >20.
- Program Prerequisites
- Trained EMS, emergency physicians, shock team, rapid ECMO response (surgeons, perfusionist), equipment, experience.
- Time from arrest to ECPR is critical.
- Cases
- 29-year-old, amniotic fluid embolism, 35 min ECPR → fem-fem VA ECMO 7 days → discharge.
- 44-year-old, SCAD in cath lab, 18 min CPR → fem-fem VA → V-AV → VV → decannulated → discharge.
- Additional survivors after 37–55 min
- Summary
- Experience matters.
- ECPR, if done well and early, saves lives.