Conventional cardiopulmonary resuscitation or CPR, combines rescue breathing with chest compressions, and has been the primary treatment for cardiac arrest for nearly 60 years. Survival, however, remains frustratingly low. Brigham and Women’s Hospital is part of a collaborative effort to explore a promising new alternative: extracorporeal CPR (ECPR).
With ECPR, early CPR for cardiac arrest patients is followed by extracorporeal membrane oxygenation (ECMO). By oxygenating and circulating the patient’s blood, the technique buys physicians more time to identify—and, if possible, repair—the underlying problem.
The Brigham is one of five adult ECMO centers in Boston that has teamed with Boston Emergency Medical Services (EMS) to develop and implement a new ECPR protocol. The protocol went live at the Brigham in February 2024. Two months later, the Brigham’s STRATUS Center for Medical Simulation, Department of Emergency Medicine, divisions of Thoracic Surgery and Cardiac Surgery, and Boston EMS worked together to simulate a complete ECPR resuscitation.
“If you have cardiac arrest at home, depending on where you live, you’ll have anywhere from a 1% to a 10% chance of survival,” says Paul S. Jansson, MD, MS, lead for quality and safety programs at STRATUS. “We need to figure out what else we can do to prevent these sudden deaths. That’s where ECPR comes in.”
ECPR Protocol Designed for Subset of Cardiac Arrest Patients
University of Minnesota cardiologist Demetri Yannopoulos, MD, has spearheaded the development of an ECPR protocol designed for a specific subset of cardiac arrest patients. Among the key inclusion criteria:
- Between ages 18 and 70 years
- CPR initiated within 10 minutes of arrest
- A shockable initial rhythm
- No return of spontaneous circulation after three defibrillation attempts
- Arrival at the receiving facility within 30 minutes of arrest
In early 2023, the five ECMO centers and Boston EMS began collaborating on an ECPR protocol for Greater Boston. Over the ensuing year, the parties met monthly to refine the protocol and achieve state approval.
“You can’t have a successful protocol without the buy-in and investment of the pre-hospital services and team, so the involvement of Boston EMS has been instrumental,” says Raghu R. Seethala, MD, medical director of the Brigham’s ECMO Service and chief of the Division of Emergency Critical Care Medicine. “This is a case of the ECMO centers and EMS coming together to do something for the greater good of the community.”
As Dr. Seethala notes, simply having an ECMO machine does not constitute an ECPR program. The protocol thus spans all aspects of an ECPR resuscitation.
EMS personnel who arrive on the scene must rapidly assess the patient to determine if they meet the criteria for ECPR activation. If three rounds of chest compressions and defibrillation fail to reestablish a pulse, the patient is transported via ambulance to the nearest adult ECMO center. This is a shift from past practice, where EMS personnel would deliver more intensive care at the scene and/or transport the patient to the nearest hospital, regardless of whether it had an ECMO program.
Once the patient arrives at the hospital, the new protocol calls for instant, seamless collaboration among multiple services.
“The ECMO team, the Emergency Department, nursing, anesthesiology, cardiac surgery, thoracic surgery, cardiology, interventional cardiology, the ICU, ICU nursing leadership—when that patient hits the door, everybody must be prepared to get that patient on ECMO and do all the necessary things to care for them afterwards,” Dr. Seethala says. “All of the stakeholders have to buy into this because they all play a role.”
Creating a Lifelike Environment for ECPR Simulation
Due to the specifics of patient criteria and the number of ECMO centers in the area, Dr. Jansson expects that the Brigham will not handle many ECPR cases. Running a simulation with Boston EMS would thus allow participants to sharpen their skills and identify weaknesses.
To kick off the simulation, Boston EMS paramedics and EMTs were dispatched to an offsite location, where a high-fidelity manikin was waiting. Meanwhile, an alert sounded in the Emergency Department announcing the imminent arrival of a candidate for ECPR.
Traveling by ambulance, EMS personnel delivered the manikin via the ambulance bay door. The manikin was then brought to the Emergency Department’s resuscitation room, where the cardiac surgery team placed it on an ECMO machine.
“From start to finish, our goal was to practice everything and make it as realistic as possible so that we could find all of the opportunities for improvement and fix them before the next patient comes in,” Dr. Jansson says.
“We have a long history of coordinating with hospitals to ensure appropriate patient distribution, notifications, and transfer of care,” adds Susan Schiller, Boston EMS deputy superintendent. “Personnel greatly appreciate opportunities such as this to run through scenarios, allowing crews to gain comfort and skill with this new protocol.”
The Road Ahead for ECPR in Boston
Moving forward, the Brigham will continue to work with Boston EMS and the other ECMO centers to modify the ECPR protocol as needed. Reena Underiner, MD, Boston EMS assistant medical director, likes what she has seen so far.
“The department is encouraged by the rollout of this medical advancement,” she says. “We will closely monitor the new protocol to ensure a high level of care during this initial implementation phase and after.”
Drs. Seethala and Jansson, meanwhile, will continue to embrace the Brigham’s role as an early but cautious adopter of innovations like ECPR.
“It’s crucial that we stay abreast of these newer technologies, therapies, and protocols to give the best care possible for the sickest patients possible,” Dr. Seethala concludes.