Allegheny General Hospital, City of Pittsburgh EMS Join Forces to Introduce New Resuscitation Protocol for Out of Hospital Cardiac Arrest Incidents

Monday, September 09, 2024

Press Releases Allegheny General Hospital Cardiovascular Institute

New ECMO-supported Method has Seen Dramatically Improved Survival Rates in Eligible Patient Populations Nationwide; Currently, Less Than 10% of Patients Survive Out-of-Hospital Incidents, Even After Treatment

PITTSBURGH - Allegheny General Hospital (AGH), the flagship academic medical center of Allegheny Health Network (AHN), has partnered with the City of Pittsburgh Emergency Medical Services (EMS) and regional EMS teams to formally launch a new resuscitation program for patients who suffer an out-of-hospital cardiac arrest.

The new emergency response model, which utilizes a type of heart-lung bypass machine to supplement conventional resuscitation methods such as chest compressions and automated external defibrillation, has been shown to dramatically improve cardiac arrest survival rates for certain patient populations.

Cardiac arrest occurs when the heart suddenly stops pumping, and it's typically caused by heart arrhythmia, which is usually brought on by a heart attack, clogged arteries, or congenital heart defects.

When sudden cardiac arrest happens outside of the health care setting, it's nearly always deadly - more than 350,000 people experience out-of-hospital cardiac arrests annually in the U.S., and of those about 10 percent survive long enough to be discharged from a hospital, even when treated by EMS.

But the new method - called extracorporeal CPR (ECPR), which relies on a cardio-pulmonary life support device known as an extracorporeal membrane oxygenation (ECMO) machine - is proving to be a game-changer because it gets oxygenated blood pumping to the organs, giving doctors more time to correct the underlying problem.

AHN and regional EMS teams have been utilizing ECPR for cardiac arrest victims since 2021 but in a limited, pilot-program capacity. The expanded ECPR program at AGH is now supported by a round-the-clock ECMO resuscitation team that can administer and oversee ECPR care from the facility's emergency department.

Pittsburgh EMS has integrated the Prehospital ECMO Program as one of its core critical care programs and does continuous training and quality improvement efforts to maximize the number of patients eligible to benefit from the program.

"Every second counts when it comes to restoring blood flow to the brain," said Subbarao Elapavaluru, MD, FCCM, Surgical Director, AGH ECMO Program, Co-Director, Division of Surgical Critical Care & CT- SICU. "ECPR has the potential to revolutionize the way hospitals and EMS treat cardiac arrest, and where it's being utilized, it's already been shown to significantly improve survival rates and preserve brain function. We're thrilled to bring this medical advancement to more patients throughout Pittsburgh."

Traditionally, after a person experiences cardiac arrest, EMS is called and responders begin efforts to revive and stabilize patients prior to transport. But the new EMS protocol calls for transporting eligible patients as quickly as possible to participating ECPR facilities, such as AGH, instead of exhausting all efforts - and valuable minutes - in the field. Mechanical chest compressions and defibrillation efforts can continue throughout transport, but the key is to get the patient to a hospital immediately.

Patients must meet certain clinical and distance parameters for this protocol to be enacted - they must be within 45 minutes of a designated ECPR facility in Pittsburgh, and their heart must respond to a defibrillator (meaning it has a "shockable rhythm") to be considered a candidate for ECPR.

"To give the brain the best chance to recover, studies show that we have to have these patients on ECMO within 45-60 minutes of their cardiac arrest," said Tyler VanDyck, MD, Co-Director of the AHN Cardiothoracic Surgical ICU and Medical Director of ECMO at AGH.

When AGH receives an ECPR transport, the patient is placed on an ECMO machine, which takes over the work of the heart and lungs to pump oxygenated blood throughout the body. The ECMO system is connected to the patient through plastic tubes (cannulas) placed in large veins and arteries - the blood is removed from the body, oxygenated, then recirculated. Once stabilized, patients may then undergo stent placement or other procedures to correct the cause of the arrest.

"ECMO in itself does not treat the underlying cardiovascular disease, but it does provide fresh blood flow to the brain and other organs to give the body a chance to rest and increase the amount of time physicians have to fix the issue," Dr. Elapavaluru said. "Today's announcement further legitimizes the ongoing work we've put into formalizing and spreading awareness of this critically important initiative."

Physician researchers from the University of Minnesota Medical Center, which pioneered ECPR, led a clinical trial evaluating the efficacy of the resuscitation therapy in the case of cardiac arrest incidents. The ARREST Trial, published in The Lancet (doi: 10.1016/S0140-6736(20)32338-2), demonstrated that the ECPR control group had significantly better outcomes when compared to subjects who received standard resuscitation care.

Other trials, including INCEPTION (doi: 10.1056/NEJMoa2204511), published in the New England Journal of Medicine, and PRAGUE-OHCA (doi: 10.1001/jama.2022.1025), published in JAMA, yielded less favorable results but did increase overall learnings for ECPR administration.

"We have learned from these trials that the full continuum of care - from bystander CPR and EMS response to the hospital-based care - is extremely important, and a highly trained team and optimized system is needed to achieve the best possible results," said Dr. VanDyck.

In the past 12 months, AHN administered ECPR to seven out-of-hospital cardiac arrest patients in Pittsburgh. Three of them (43%) survived to discharge, a rate that is far higher than the national survival rate of just standard resuscitation alone, without ECMO (10%).

"Without ECMO, the data suggests that these patients certainly would not have survived," said Dr. Elapavaluru.

The sooner ECMO therapy begins, the better the results - there's a nearly 100% chance of reviving patients with certain types of cardiac arrest if ECMO is administered within 30 minutes of collapse, and a 50% chance after 40 minutes, according to research from the University of Minnesota Medical Center.

"For patients to be eligible for this new resuscitation approach, bystander CPR must have been started within five minutes of the cardiac arrest incident," said Mark E. Pinchalk, MS, EMT-P, Assistant Chief of City of Pittsburgh EMS. "These parameters underscore how critical it is for the public to be trained and educated in CPR and AED skills, so that they can assist victims before our crew arrives on scene."

Ross West View Emergency Medical Services Authority and Shaler/Hampton EMS also participate in the ECPR program.

In addition to Drs. Elapavaluru and VanDyck, the launch of EMS-activated ECMO was led by the late Michael Collins, MD, former Surgical Director of the AGH ECMO Program, Emergency Physicians Philip Nawrocki, MD, Matthew Poremba, DO, and Chadd Nesbit, MD, Ph.D., Interventional Cardiologists Mithun Chakravarthy, MD, Karthik Ranganathan, MD, and David Lasorda, DO as well as Stephen Bailey, MD, Chair of AHN Cardiovascular Institute and Tom Campbell, MD, former Chair of AHN's Emergency Medicine Institute.

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