ECMO in EMS: Pitfalls and possibilities
How to recognize and mitigate extracorporeal membrane oxygenation complications during EMS transport
Leon Eydelman, MD, emergency medicine and critical care physician at Advocate Christ Medical Center in Oaklawn, Illinois, presented a session called “ECMO Management: Pitfalls and Possibilities” at EMS World Expo.
In this session, Eydelman described the basics of ECMO, how it is used to treat critical patients, and how advancements in technology will impact the role EMS plays in the transport of these patients.
Memorable quotes on ECMO in EMS
Here are some memorable quotes from Eydelman on ECMO prehospital patient transport.
“ECMO can help save lives.”
“ECMO is taking off. If you haven’t seen it yet, you will.”
“It is not a death sentence. It is not a last-ditch attempt to just do something to someone as they die.”
“The more we know about it, the better we are at treating our patients.”
“Paralysis is preceded by good sedation you don’t want them to move during transport.”
Top takeaways on ECMO in EMS
Here are the key takeaways from Eydelman’s presentation on ECMO possibilities in EMS transport.
1. What is ECMO?
Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support (ECLS) or extracorporeal cardiopulmonary resuscitation (ECPR), is a lifesaving technique to provide extended cardiac and respiratory life support to continually deliver an adequate amount of gas exchange or blood flow to the body. Eydelman explained, “when we have these young healthy people with these horrific but compartmentalized injuries, this is an ideal solution to their problem.”
ECMO is used to treat patients who have suffered from a cardiac arrest/cardiogenic shock involving pulseless electrical activity or respiratory failure. Eydelman described the use of ECMO to control the flow of the blood through the body using a pumping system to oxygenate and remove carbon dioxide from hemoglobin in the red blood cells.
Stub et al. (2015) provides the following standard definition of both types of ECMO:
- Veno-venous (VV) ECMO (lung): “used to support respiratory conditions, the lungs are bypassed and the membrane oxygenator completes the function of the lungs. The patient’s circulatory function is maintained by the system.”
- Veno-arterial (VA) ECMO (heart-lung): “Commonly used for cardiac failure and cardiac arrest, deoxygenated venous blood from the right atrium is drained by one cannula and passed through an external oxygenator, which serves to oxygenate the blood and remove carbon dioxide. The oxygenated arterial blood is then pumped back into the proximal aorta under pressure by a return cannula in the to complete the circuit.”
Large-bore catheters and external pumps work in a systematic circuit through cannulas. Strategically placed sensors regulate the amount of blood pushed and pulled into the cannulas to complete the circuit.
ECMO can be used to treat patients with severe heart and lung conditions, including:
Acute lung failure, such as flare-ups of emphysema and asthma
Acute respiratory distress syndrome
Post-surgery cardiac failure
2. How to mitigate and recognize possible complications during EMS transport
ECMO has shown a lot of success in the medical field when treating patients who are otherwise difficult to resuscitate. It is not common practice for EMS to be involved in the initial placement of the ECMO system, however, there has been an increase in the amount of transfers requested for ECMO patients. Eydelman advised prior to transport it is beneficial “to have a collaborative discussion on what is needed and what is not needed during transport.” He suggested discussing the following points prior to leaving the hospital:
- Talk with the physicians and nursing staff about minimizing medications and devices that are not needed during transport. If possible, providers should prearrange push doses with nurses for easy administration during transport and minimize drips that are not needed.
- Calibrate the ECMO display before moving the patient to ensure its functioning properly.
“If you’re uncomfortable about how the sites are, tell them,” advised Eydelman. Examine all cannula sites to ensure secure placement and keep slack when transporting a patient.
Hospital critical care teams are well versed on the intricate set up of patients on ECMO. Eydelman urged prehospital providers “to become familiar with ECMO, how it benefits the patient, and prepare for any complications en route.”
Eydelman asked providers to keep in mind some potential perfusion problems and pressure alarms that may occur during transport:
- Vital signs may be misleading
- Remember ventilator is mostly for show and may not be needed
- Keep BP in the sweet spot
- Utilize your ECMO pressures/display
- Maintaining adequate sedation and paralysis is important in ECMO patients, especially while in transport
- Volume status as the blood flows through the circuit
- Patient’s resistance – the more pressure, the more flow, the more complications can occur
- Blood clots may appear in the filter or air may enter the cannula causing death
3. Recent advances for ECMO EMS transport
Advancement in portable ECMO devices have allowed critical care teams the ability to treat cardiac arrest and respiratory failure patients in the field by specialized teams. The Paris emergency medical services has created mobile intensive care units that are prioritize by a medical physician assigned to emergency call center. Mobile teams are comprised of an emergency physician, nurse, and paramedic.
In the United States, the University of New Mexico Health Sciences and the Albuquerque Fire Rescue recently deployed the first prehospital ECMO team to bring life-saving techniques to treat a cardiac arrest patient in the field.
ECMO is also migrating to the emergency department as well. The Emory ECMO Center and Vanderbilt Heart ECMO Program are already providing treatment and transport services.
Eydelman believes prehospital providers “have the moral authority and the intelligence to suggest this at times when it’s happening.”
Additional resources on ECMO
Learn more with these resources from EMS1:
- A prehospital approach to refractory ventricular fibrillation
- 10 things EMS providers need to know about ECMO
- ECMO: 5 things paramedics need to know
- Assy, J., Fawzi, I., Arabi, M., Bulbul, Z., Bitar, F., Majdalani, M., ... & El Rassi, I. (2018). ECMO is in the air: Long distance air/ground transport of a child on extra corporeal membrane oxygenation. The Egyptian Journal of Critical Care Medicine, 6(3), 151-153.
- Emory Medicine. ECMO Center. http://ecmo.emory.edu/
- Stub, D., Bernard, S., Pellegrino, V., Smith, K., Walker, T., Sheldrake, J., . . . Kaye, D. M. (2015). Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation, 86, 88-94. doi:10.1016/j.resuscitation.2014.09.010
- Vanderbilt Health. Vanderbilt Heart. Extracorporeal Membrane Oxygenation (ECMO) Program. https://www.vanderbilthealth.com/heart/54346
- Washington, F (2019). Albuquerque first responders perform life-saving procedure for the first time. https://www.krqe.com/news/albuquerque-metro/albuquerque-first-responders-perform-life-saving-procedure-for-the-first-time/
This article was originally posted Feb. 19, 2020. It has been updated.