ECMO is a form of extracorporeal life support that oxygenates and removes carbon dioxide from the blood. It is being considered in the emergency department for patients experiencing refractory ventricular fibrillation during cardiac arrest. ECMO may improve survival rates and neurological outcomes compared to conventional CPR. There are indications and contraindications for its use in acute, severe reversible respiratory or cardiac failure. The two main types are veno-venous ECMO for respiratory failure and veno-arterial ECMO for cardiac failure. Proper patient selection, cannulation technique, and circuit management are important considerations for ECMO in cardiac arrest.

1. ECMO in Cardiac Arrest
Johnny iliff

2. references
 LITFL
 Alfred Hospital
 ECMO Project

3. What is it?
 ECMO is extra-corporeal membrane oxygenation
 extracorporeal life support (ECLS) may be a better term
 The extracorporeal circuit allows for the oxygenation and
removal of carbon dioxide from blood
 used as a supportive strategy in patients who have a high risk
of death despite conventional therapy

4. Why are we considering it in the ED for
CardiacArrest
 “Patients with refractory ventricular fibrillation receiving E-
CPR tended to have higher survival rates and significantly
improved neurological outcomes when compared with those
receiving C-CPR”. Managing cardiac arrest with refractory ventricular fibrillation in
the emergency department:Conventional cardiopulmonary resuscitation versus
extracorporeal cardiopulmonary resuscitation􏰀 -Fu-Yuan Siao et al. RESUSCITATION April
2015
 Drive to start ECMO in SCGHED

5. Indications
 acute, severe REVERSIBLE respiratory or cardiac failure with
a high risk of death that is refractory to conventional
management
 poor gas exchange
 compliance < 0.5mL/cmH2O/kg
 P:F ratio < 100
 shunt fraction > 30%

6. Absolute Contraindications
 progressive non-recoverable cardiac disease (not transplant
candidate)
 progressive and non-recoverable respiratory disease (irrespective
of transplant status)
 chronic severe pulmonary hypertension
 advanced malignancy
 GVHD
 >120kg
 unwitnessed cardiac arrest

7. Relative Contraindications
 age > 75
 multi-trauma with multiple bleeding sites
 CPR > 60 minutes
 multiple organ failure
 CNS injury

8. Types
 VV = veno-venous
 VA = veno-arterial: peripheral or central
 Veno-pulmonary artery ECMO (provides short-term right
ventricular and respiratory support following LVAD insertion)
 high (2 venous cannulae) vs low flow (1 venous cannula)

9. VV ECMO
 most common mode
 venous drainage from large central veins -> oxygenator ->
venous system near RA
 support for severe respiratory failure (no cardiac dysfunction)
 Proven to be improve survival @6months (63% vrs 47%) with
acute respiratory failure

10. VV ECMO

11. Pathology
 pneumonia
 ARDS
 -acute GVHD
 pulmonary contusion
 smoke inhalation
 status asthmaticus
 airway obstruction
 aspiration
 bridge to lung transplant
 drowning

12. VA ECMO
 venous drainage from large central veins -> oxygenator ->
arterial system in aorta
 support for cardiac failure (+/- respiratory failure)

14. Pathology
 graft failure post heart or heart lung transplant
 non-ischaemic cardiogenic shock
 failure to wean post CPB
 bridge to LVAD
 drug OD
 Sepsis
 PE
 cardiac or major vessel trauma
 massive pulmonary haemorrhage
 pulmonary trauma
 acute anaphylaxis

15. The ALFRED guidelines
 Patients in the E&TC with out-of-hospital cardiac arrest which is refractory to
standard advanced cardiac life support (ACLS) treatmentAND:
 The patient meets ALL the following criteria in regards to the characteristics of
the arrest:
 Likely due to Respiratory or Cardiac cause
 Witnessed arrest
 Chest compressions started within 10 mins
 Less than 60 mins duration in total
 12-70 years old
 No major co-morbidities

16.  The patient is profoundly hypothermic (<32°C) due to
accidental exposure
 The patient has taken a significant overdose of a vaso-active
drug(s) (i.e. β-Blocker, tricyclic acid, digoxin etc)
 Any other cause where there is likely to be reversibility of the
cardiac arrest if an artificial circulation can be provided
 In order to ensure that out-of-hospital cardiac arrest patients
arrive within a short time-frame, eligible patients will be
transported by ambulance with an AutopulseTM as soon as
possible after the initiation of ACLS

17. STEPs
1. Identify potential patient
2. US guided Line-Venous and Arterial (Training Required)
3. Prime Circuit (Training Required)
4. Attach Circuit
5. Intensive Care
6. Optimize and treat potential casues

18. Cannulation
 It’s central access, what’s the big deal?

22. The Circuit

23.  https://www.youtube.com/watch?v=OM27HovykWY