Performance of Extracorporeal Cardiopulmonary Resuscitation Pathway for Out-of-Hospital Cardiac Arrest in Washington, District of Columbia

The 2020 ARREST trial demonstrated that Extracorporeal Cardiopulmonary Resuscitation (ECPR) using VA-ECMO improves neurologically intact survival in carefully selected out-of-hospital cardiac arrest (OHCA) patients. In 2021, in Washington, DC, a large, urban, fire-based EMS agency (the Dept.) implemented an ECPR pathway directing transport of refractory VF/pVT patients to ECMO-capable centers; real-world utilization has not been evaluated. This study assesses pathway performance by examining OHCA characteristics, identifying ECPR-eligible patients, and evaluating utilization and outcomes in 2024, allowing for maturation of the protocol since initial implementation.

We conducted a retrospective review of all OHCA managed by the Dept. in 2024 using Cardiac Arrest Registry to Enhance Survival, EMS reports, ZOLL Case Review, and the CRISP DC Health Information Exchange. Inclusion criteria were non-traumatic OHCA with attempted resuscitation. ECPR candidates were identified per the Dept.’s ECPR protocol: witnessed arrest, age 18-70 years, early CPR, initial VF/pVT refractory to ≥3 defibrillations and amiodarone or lidocaine, and LUCAS-compatible body habitus. Descriptive statistics characterized eligibility, exclusions, and outcomes.

Among 742 non-traumatic OHCA events in DC in 2024, 301 were witnessed and of those 65 had early CPR with initial VF/pVT. 25 patients had refractory VF/pVT; 11 met the Dept.’s ECPR criteria. 14 were excluded due to age >70 (n=7), no anti-arrhythmic administration (n=2), sustained ROSC (n=2), or LUCAS incompatibility (n=3). Mean on-scene time for eligible patients was 38 minutes (range=19-77). Of the 11 patients eligible for ECPR, 10 were transported to an ECMO center (3 outside of the hours of ECMO availability) and 1 to a non-ECMO facility. Only 1 patient (9% utilization) underwent ECPR cannulation and died from a non-ECMO-related complication, 6 of 7 transported died in-hospital, and 1 survived with favorable neurological outcome.

Few OHCA patients met ECPR criteria and utilization was low. Prolonged on-scene times and variable destination selection may have contributed to missed ECPR opportunities. Findings are limited by small sample size. Future work should prioritize improving execution of the existing pathway, improving protocol adherence, and reducing prehospital delays and transport to ECMO-capable centers.