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Critical Care Medicine

Extracorporeal Cardiopulmonary Resuscitation in the Emergency Department

Joseph Tonna, MD
Newsletter Editor

Getting to write about the use of extracorporeal life support (ECLS) in the emergency department (ED) is a treat for me. Since fellowship, I have looked at ECLS as the type of therapy that would revolutionize medical care, akin to hemodialysis, antibiotics or surgery. Since that time, I have trained to learn about ECLS such that it could be used to improve the care and survival of patients from a variety of otherwise morbid or fatal conditions.

My experience with extracorporeal cardiopulmonary resuscitation (eCPR) in the ED started a few months after my arrival as new faculty at the University of Utah. I was approached by an emergency physician colleague and cardiac arrest researcher, Scott Youngquist, MD, who wanted to implement an ED ECMO program. As an emergency intensivist, specializing in the cardiothoracic ICU, I was the bridge between cardiothoracic (CT) surgery, and the ED. Over the next 12 months, we planned, designed and tested a program of eCPR in the ED.

Over these months, we spent time learning and discussing our program with other physicians across the country, in order to learn from their experiences and create a successful program. ELSO, the Extracorporeal Life Support Organization, was a wonderful resource during this time, and for anyone interested in ECLS, this is the first place to start for education, guidance and community. As we started to build our program, we started having regular meetings among emergency physician colleagues across the country who had successfully been doing eCPR for years, including Zach Shinar and Joe Bellezo at Sharpe Memorial, David Gaieski and Lance Becker, Atman Shah from the University of Chicago, Kyle Gunnerson (recently relocated to the University of Michigan) and the folks at University of Pennsylvania. In talking with these colleagues and programs, we learned the variety of ways in which eCPR was activated, implemented, and transitioned to the inpatient setting.Across the country, everyone from CT surgery, emergency medicine, trauma surgery, to cardiology was initiating eCPR. From these experienced programs, we have learned much.

These discussions soon became a regular occurrence, and we recognized that the group of physicians providing eCPR in the ED was small, but collectively had much experience. To leverage this experience and study eCPR, we formed the Extracorporeal REsuscitation ConsorTium (ERECT) (www.erectcollaborative.org). We identified the mission of the ERECT collaborative to include dissemination and discussion of best practice and education from each other’s experiences and eCPR clinical trials. We’ve found the collaborative meetings very rewarding and informative, and our membership has been growing.

Through this process, we learned that the University of Utah program was noteworthy, if not unique among centers performing eCPR, in that we designed it around very formal processes for activation and management (such as emergency physician activation) and formal post-cannulation interventions, including cardiac catheterization, targeted temperature management and prognostication. (Tonna, Resuscitation, In Press)

We have had very good patient outcomes, and attribute them to this structured process and healthily relationships between all members of a highly multidisciplinary program, including emergency medicine, nursing, perfusion, CT surgery, cardiology and neurology. We believe strongly that the best eCPR programs grow from robust and mature inpatient ECLS programs. Additionally, we have found that if there is a clear programmatic vision for eCPR, and time spent with all ECLS stakeholders, that the program grows very naturally from a clinical need, rather than from the desire of any one group to “do ED ECMO.”

Based on the experiences of ERECT sites with ECLS in the ED, there is no question in my mind that ECLS use for a variety of indications will grow, both in the hospital and in the ED. Some of our members, such as Jarrod Mosier and Kyle Gunnerson, have published on the expanding and future use of ECMO in the ED. (Mosier, Critical Care, 2015)

Given a rush of emergency physicians to critical care, it is not unexpected that a traditionally “ICU” therapy such as ECMO would be increasingly deployed in the ED for resuscitation. As emergency intensivists, it is our obligation to our critical care colleagues and to our emergency physician colleagues to help shepherd this therapy into the ED in a controlled and responsible way. The number of times I’ve been asked, “Cool program, but who gets to cannulate?” is a testament to a lack of understanding of the magnitude of an ECMO program. For those of us who manage ECLS, cannulation is such a small part.

EM/CCM physicians—in our role as natural links between the ED and the ICU—need to lead our ED colleagues towards a more broad understanding of the full spectrum of ECMO care, and yet also educate our inpatient colleagues on the benefit of rapid and effective implementation of ECLS during resuscitation. I firmly believe that as EM/CCM physicians, we can bring together the diverse specialties involved in ECMO care, and create an efficacious multidisciplinary eCPR team. Clearly emergency physicians can cannulate for ECMO, though as an EM/CCM specialty, we need to focus on ensuring appropriate patient selection and post cannulation management, and the initiation of and cannulation for ECMO will follow naturally. It should matter very little to us who cannulates, and matter very much who we put on ECMO and how we manage them.

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