Interviewer: It's a new technique that some emergency rooms are using to save lives. Learn about eCPR. That's next on The Scope.
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Interviewer: So you've heard of CPR, what happens when you throw an E in front of it and you get eCPR? Well, it's a new technique that we're going to learn a little bit more about from an emergency room physician, Dr. Scott Youngquist. What is eCPR? What does that stand for?
Dr. Youngquist: eCPR stands for extracorporeal cardio pulmonary resuscitation, and the idea is that instead of pressing on the chest rhythmically to circulate blood, you actually withdraw blood from the patient and using a mechanical pump, pump it back into the patient, fully oxygenated and under pressure.
Interviewer: All right. What was this born out of?
Dr. Youngquist: Well, this goes back decades to really the 1930s with the development of heart-lung bypass. This heart-lung bypass was used in the operating room to allow cardio-thoracic surgeons to perform blue baby operations and to perform coronary bypass. So it's been used there extensively and has been very expensive.
Interviewer: All right. And now, it's being used in the emergency room. It's kind of old technology, new application. Why is it coming to emergency rooms?
Dr. Youngquist: Well, for several reasons. One is that the cardiac arrest survival rates have not moved much in the last 30 years. So we've kind of reached the pinnacle of resuscitation using closed chest compressions and defibrillation. And unfortunately, we only get about seven and a half percent of patients out of the hospital neurologically intact and whom we attempt usual care, namely, chest compressions and defibrillation.
Interviewer: Yeah. So you're looking to up that percentage a little bit.
Dr. Youngquist: Absolutely. So one of the rationales for using this external pump is that it provides much better blood flow than just pressing on the chest.
Interviewer: And how is it doing? Is it doing better than 7%?
Dr. Youngquist: It's doing better than 7%. Several centers are reporting that in carefully selected patients, 50% of these victims are surviving once they're placed on pump and recall that these are patients in whom the standard measures have already failed.
Interviewer: Right. Because this is somebody who's had a cardiac arrest in the field, they've been put on an ambulance, the compression is probably all the way to the hospital, then they get put on more compressions at the hospital before the machine comes on? I mean how does that process even work?
Dr. Youngquist: Yeah, absolutely. So the resuscitation has to go seamlessly from the field where bystanders hopefully start chest compressions till when EMS arrives. They continue chest compressions and defibrillation attempts, identify the patient as suitable for ECMO possibly and move them to the emergency department. And then the ED, in the emergency department, we continue compressions while we try to get access for placing the patient on pump. So usually, it takes somewhere between 45 and 60 minutes at best to get the person on the pump.
Interviewer: So why aren't we putting the pumps in the ambulances for the first responders?
Dr. Youngquist: Well, that's a good question. It's a highly tactical skill, so right now it requires a physician to place the patient on the pump. And some places are actually doing this, places like Paris, France, where physicians ride on ambulances and take this machine to the field where they can insert catheters and place the patient on pump, in places like the Louvre even or a supermarket.
Interviewer: Yeah, and what are their percentages? Is it much better than the way it's currently here in the United States?
Dr. Youngquist: Well, it's too early to tell. They haven't reported fully on their outcomes, but this is an ongoing trial in Europe.
Interviewer: And the difference is there are doctors on those ambulances that can actually do that. Here in the United States, we don't have that. So when you get back to the emergency room, it's not the emergency room personnel that are actually hooking people up, it's cardiologists.
Dr. Youngquist: Well, it depends. At our institutions, it's cardiothoracic surgeons. In some locations, it's cardiologists working with the emergency physicians, and in some locations it's actually emergency physicians doing the whole thing, putting them on the pump and then admitting them to the ICU.
Interviewer: And you said people have to be screened whether or not they're going to be even eligible at this point. So they make it back to the emergency department, then there's additional criteria to determine if this pump can be used. What are those?
Dr. Youngquist: Well, we're not sure exactly which patients will benefit the most, but we have some good idea. We think it's patients that initially have a shockable rhythm and don't have a lot of comorbidities. So people who already have advanced cancer or heart failure, cirrhosis of the liver, renal failure, those patients aren't likely to benefit from this life extending care which is really heroic.
Interviewer: Yeah. So another good reason to try to stay as healthy as possible I suppose where you can.
Dr. Youngquist: Absolutely.
Interviewer: What's the future of this technology from what you're seeing right now?
Dr. Youngquist: Well, we're seeing a year-by-year expansion in use and availability of eCPR to cardiac arrest victims in the United States and elsewhere. There is a large registry called ELSO which tracks this and this has been going up exponentially each year. And part of that tracks with the scale and cost of the equipment coming down over time.
Interviewer: And then at the end of the day, you mentioned 50%, like is it a 50% increase?
Dr. Youngquist: It's about 50% of patients who go on the pump who survive, and this is a case series that's selected from patients who have already failed at least 60 minutes of usual care. In those cases, continuing CPR may result in a few survivors but it's usually less than 5%.
Interviewer: Okay. So is there a point where you have to look at the expense, the necessary equipment versus the survival rate? Is 50% a pretty good number to offset the balance of the other aspects of providing this care?
Dr. Youngquist: Yeah. I would say that's a great number considering the overall survival at that time period is less than 5%. So we've given the person a tenfold increase in survival by providing this therapy.
Interviewer: All right. And we have this technology here at University of Utah Health?
Dr. Youngquist: Yes, we do. For a couple of years, we've been providing this therapy to select patients who meet our criteria.
Interviewer: But there are some places still without it but hopefully, someday soon.
Dr. Youngquist: Yes.
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