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Extracorporeal Membrane Oxygenation in the Emergency Department for Out-of-Hospital Cardiac Arrest

      Emergency departments (EDs) and emergency medical services are motivated to increase survival after sudden out-of-hospital cardiac arrest (OHCA) (
      Institute of MedicineBoard on Health Sciences Policy
      Strategies to Improve Cardiac Arrest Survival: A Time to Act.
      ). Extracorporeal cardiopulmonary resuscitation (ECPR) has been promoted as an option, but substantial uncertainty exists regarding how to select patients (
      • Mosier JM
      • Kelsey M
      • Raz Y
      • et al.
      Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions.
      ). Recently, a single-center, randomized controlled trial demonstrated increased survival with early extracorporeal membrane oxygenation (ECMO) compared with standard care (
      • Yannopoulos D
      • Bartos J
      • Raveendran G
      • et al.
      Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial.
      ). Limited evidence demonstrates some EDs have successfully implemented ECPR (
      • Shinar Z
      • Plantmason L
      • Reynolds J
      • et al.
      Emergency physician-initiated resuscitative extracorporeal membrane oxygenation.
      ). The observational data are mixed. An overarching problem with existing data is the concept of competing risk. If patients with OHCA are being moved to ECPR centers and this was to compromise the delivery of standard Advanced Cardiac Life Support (ACLS) measures to other patients, it is possible that ECPR strategies may decrease the survival of a population of patients with OHCA. At this point, the existing evidence is not strong enough to recommend the use of ECPR for OHCA as a standard of care. Further research is needed, particularly on how the broader OHCA population would be affected.

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