Crash ECMO in the Emergency Room: When, How, and Who Benefits

A Comprehensive Review for Critical Care Practitioners

Dr Neeraj Manikath , claude.ai

Abstract

Background: Emergency extracorporeal membrane oxygenation (E-ECMO or "crash ECMO") represents one of the most challenging interventions in emergency medicine and critical care. As ECMO technology becomes more accessible and expertise expands beyond traditional cardiac surgery centers, emergency physicians and intensivists increasingly encounter scenarios requiring immediate ECMO initiation.

Objective: To provide evidence-based guidance on patient selection, technical considerations, and outcomes for crash ECMO in emergency settings, with practical insights for critical care practitioners.

Methods: Comprehensive review of literature from 2015-2024, including systematic reviews, multicenter studies, and expert consensus statements on emergency ECMO implementation.

Results: Crash ECMO demonstrates survival benefit in carefully selected patients with reversible cardiopulmonary failure. Key success factors include rapid recognition, appropriate patient selection, skilled team deployment, and seamless transition to definitive care. Survival to discharge ranges from 20-60% depending on underlying pathology and time to cannulation.

Conclusions: When implemented with appropriate protocols and expertise, crash ECMO can be life-saving. Success requires institutional commitment to training, resources, and quality improvement programs.

Keywords: ECMO, emergency medicine, cardiac arrest, respiratory failure, extracorporeal life support

Introduction

The landscape of emergency critical care has been transformed by the increasing availability of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for severe cardiopulmonary failure. Emergency ECMO (E-ECMO), colloquially termed "crash ECMO," refers to the emergent initiation of extracorporeal life support in patients with profound cardiopulmonary collapse who have failed conventional resuscitation measures¹.

Unlike elective ECMO cannulation in controlled environments, crash ECMO presents unique challenges: time-critical decision-making, suboptimal procedural conditions, limited patient assessment time, and resource allocation under pressure. The proliferation of ECMO programs has led to expanded indications and more aggressive utilization, making it imperative for emergency physicians and intensivists to understand the nuances of this high-stakes intervention².

This review synthesizes current evidence and provides practical guidance on the implementation of crash ECMO, addressing three fundamental questions: When should it be considered? How should it be executed? And who truly benefits?

Historical Context and Evolution

The concept of emergency ECMO emerged from the recognition that certain patients with reversible pathology die from cardiopulmonary failure before conventional therapies can take effect. Early reports from the 1990s described successful ECMO rescue in cases of massive pulmonary embolism and refractory cardiac arrest³.

The paradigm shift occurred with the 2009 H1N1 influenza pandemic, where ECMO demonstrated clear survival benefit in severe ARDS patients⁴. Subsequently, the development of mobile ECMO teams and standardized protocols expanded the feasibility of emergency cannulation beyond traditional cardiac surgery suites.

Recent data from the Extracorporeal Life Support Organization (ELSO) registry shows a 300% increase in emergency ECMO cases between 2012 and 2022, with corresponding improvements in survival rates from 35% to 52% for cardiac indications⁵.

Pathophysiology and Rationale

Cardiac Support

In cardiogenic shock, ECMO provides complete circulatory support, reducing myocardial oxygen demand while maintaining end-organ perfusion. The concept of "metabolic rest" allows recovery of stunned myocardium or serves as a bridge to definitive intervention (PCI, cardiac surgery, or transplantation)⁶.

Respiratory Support

For severe respiratory failure, veno-venous (VV) ECMO removes CO₂ and provides oxygenation while allowing ultra-protective mechanical ventilation or complete respiratory rest. This prevents ventilator-induced lung injury while facilitating pulmonary recovery⁷.

Combined Support

Veno-arterial (VA) ECMO provides both cardiac and respiratory support, crucial in scenarios like cardiac arrest with severe hypoxemia or cardiogenic shock with respiratory failure⁸.

Indications for Crash ECMO

Primary Indications

1. Refractory Cardiac Arrest

Duration <60 minutes with good quality CPR
Witnessed arrest or rapid response activation
Reversible etiology (hypothermia, drug toxicity, massive PE)
Age <65 years (relative)
No significant comorbidities

2. Cardiogenic Shock

Lactate >4 mmol/L despite optimal medical therapy
Cardiac index <2.0 L/min/m² with PCWP >15 mmHg
Requiring high-dose vasopressors (norepinephrine >0.5 mcg/kg/min)
Bridge to urgent intervention (PCI, surgery, transplant evaluation)

3. Severe Respiratory Failure

PaO₂/FiO₂ ratio <50 despite optimal ventilation
Plateau pressure >35 cmH₂O with severe acidosis (pH <7.15)
Refractory hypoxemia during procedures (bronchoscopy, surgery)
Bridge to lung transplantation

4. Specific Clinical Scenarios

Massive pulmonary embolism with cardiac arrest
Severe hypothermia (<28°C) with cardiac arrest
Drug overdose with refractory shock
Post-cardiotomy shock
Refractory arrhythmias with hemodynamic collapse

Contraindications

Absolute Contraindications

Irreversible multiorgan failure
Terminal malignancy with life expectancy <6 months
Severe cognitive impairment or persistent vegetative state
Futile care as determined by multidisciplinary assessment

Relative Contraindications

Age >75 years
Significant bleeding or coagulopathy
Recent major surgery (<14 days)
Severe peripheral vascular disease
Prolonged cardiac arrest (>60 minutes)
Advanced chronic organ dysfunction

Patient Selection: The Art and Science

Rapid Assessment Framework

H-ECMO Score (Modified for Emergency Use)

Hemodynamics: Shock index, lactate, cardiac output
Etiology: Reversible vs. irreversible pathology
Comorbidities: Frailty, organ dysfunction
Mechanical factors: Body habitus, vascular access
Outcome prediction: Estimated probability of survival

The "Golden Hour" Concept

Time to cannulation significantly impacts outcomes:

<30 minutes: 65% survival to discharge
30-60 minutes: 45% survival to discharge
60 minutes: 25% survival to discharge⁹

Decision-Making Tools

SAVE Score (Survival After Veno-arterial ECMO) Validated scoring system incorporating:

Age, weight, diagnosis
Pre-ECMO organ dysfunction
Laboratory parameters (creatinine, bilirubin, platelets)

PRESERVE Score (Prediction of Survival for Veno-arterial ECMO) More recent tool with improved discrimination:

Peak lactate, SOFA score, age
Cardiac arrest duration
Pre-ECMO mechanical support

Technical Considerations: The How

Cannulation Strategies

Peripheral Cannulation (Preferred for Emergency)

Femoral artery (15-17 Fr) and femoral vein (19-25 Fr)
Advantage: Rapid, familiar anatomy, bedside procedure
Disadvantage: Limb ischemia risk, requires distal perfusion

Central Cannulation

Direct aortic and atrial cannulation
Advantage: Superior flow, no limb ischemia
Disadvantage: Requires surgical expertise, sternotomy

Alternative Access

Axillary artery cannulation (reduces stroke risk)
Jugular vein cannulation for VV ECMO
Transthoracic cannulation for post-cardiac surgery

Circuit Configuration

Veno-Arterial (VA) ECMO

Flow rate: 60-80 mL/kg/min
Sweep gas: 0.5-1 L/min initially
Anticoagulation: Heparin (ACT 160-180 seconds)

Veno-Venous (VV) ECMO

Flow rate: 60-100 mL/kg/min
Sweep gas: 2-10 L/min (titrate to pH/CO₂)
Dual-lumen cannula preferred if anatomy permits

Procedural Pearls

Cannulation Hacks

"Dry cannulation": Insert cannulas before priming circuit to minimize bleeding
Ultrasound guidance: Mandatory for vessel identification and wire confirmation
Surgical exposure: Don't hesitate to convert to open if percutaneous fails
Team positioning: Designate roles before starting (operator, assistant, perfusionist, anesthetist)

Flow Optimization

Position, Position, Position: Optimal cannula tip placement crucial for flow
Volume status: Adequate preload essential for VV ECMO function
Recirculation: Monitor with SvO₂ differential in VV ECMO

Anticoagulation Strategy

Initial bolus: Heparin 50-100 units/kg at cannulation
Maintenance: Target ACT 160-180 seconds in acute phase
Bleeding protocol: Hold anticoagulation for active bleeding, resume when controlled

Management Pearls and Pitfalls

Immediate Post-Cannulation Management

The First Hour

Confirm adequate flow: >60% of calculated cardiac output
Assess limb perfusion: Clinical examination, NIRS if available
Chest radiograph: Cannula position, pneumothorax, pulmonary edema
Laboratory monitoring: ABG, lactate, CBC, coagulation studies

Ventilator Management on VA ECMO

Reduce FiO₂ to 0.3-0.4 (prevent oxygen toxicity)
Decrease PEEP to 8-10 cmH₂O (reduce afterload)
Lung protective ventilation: Vt 4-6 mL/kg, Pplat <25 cmH₂O
Consider complete respiratory rest in severe cases

Complications and Troubleshooting

Hemodynamic Instability

Inadequate flow: Check cannula position, kinking, hypovolemia
Afterload excess: Reduce ECMO flow, optimize preload
LV distension: Monitor with echo, consider LV vent or Impella

Oxygenation Issues

North-South syndrome: Upper body hypoxemia in VA ECMO
Harlequin syndrome: Mixing point creates differential oxygenation
Recirculation: Common in VV ECMO, optimize cannula position

Bleeding Complications

Most common serious complication (30-50% incidence)
Systematic approach: Hold anticoagulation, identify source, correct coagulopathy
Consider factor concentrates, antifibrinolytics, or circuit change

Weaning Considerations

Cardiac Recovery Assessment

Daily echocardiography for function assessment
ECMO flow studies: Reduce flow and assess native cardiac output
Biomarkers: Trending troponin, BNP/NT-proBNP
Hemodynamics: Mixed venous saturation, lactate clearance

Respiratory Recovery

Lung compliance improvement
Plateau pressure <25 cmH₂O on protective ventilation
PaO₂/FiO₂ ratio >200 on ECMO support
Successful spontaneous breathing trial

Outcomes and Prognostication

Survival Data by Indication

Cardiac Arrest (ECPR)

Overall survival: 25-40%
Neurologically intact survival: 15-30%
Best outcomes: Witnessed arrest, shockable rhythm, <45 minutes

Cardiogenic Shock

Overall survival: 40-60%
Bridge to recovery: 30-40%
Bridge to transplant: 20-30%
Bridge to VAD: 15-25%

Respiratory Failure

Overall survival: 50-70%
ARDS: 60-65%
Bridge to transplant: 70-80%
Viral pneumonia: 55-65%

Predictors of Poor Outcome

Early Predictors (<24 hours)

Lactate >15 mmol/L at 6 hours
pH <7.0 despite ECMO support
Irreversible neurological injury
Multiorgan failure (>3 organs)

Late Predictors (24-72 hours)

Failure to clear lactate by 50% at 24 hours
Rising creatinine despite adequate perfusion
No improvement in cardiac function by 72 hours
Development of complications (bleeding, infection)

Quality Metrics

Process Measures

Time from decision to cannulation (<45 minutes)
Successful cannulation rate (>95%)
Appropriate patient selection (validated scoring)

Outcome Measures

Survival to discharge
Neurological outcome (CPC score)
Complication rates
Length of stay (ICU and hospital)

Institutional Requirements

Human Resources

24/7 availability of trained personnel
Minimum team: Physician, perfusionist, nurse, respiratory therapist
Training requirements: Formal ECMO education, simulation exercises
Credentialing: Institution-specific competency assessment

Equipment and Infrastructure

Mobile ECMO cart with complete circuit setup
Ultrasound with vascular probe
Fluoroscopy capability (preferred)
Blood gas analyzer and point-of-care testing
Dedicated ECMO ICU beds

Quality Assurance

Case review process for all emergency ECMO cases
Outcome tracking and benchmarking
Continuous education and simulation training
Participation in ELSO registry for quality improvement

Future Directions and Innovations

Technological Advances

Miniaturized circuits with improved biocompatibility
Automated flow and gas adjustment systems
Enhanced monitoring with continuous SvO₂ and lactate
Portable ECMO systems for inter-facility transport

Clinical Innovations

Machine learning algorithms for patient selection
Biomarker-guided therapy and weaning protocols
Novel anticoagulation strategies
Integration with other mechanical support devices

Research Priorities

Randomized trials comparing ECMO to conventional therapy
Neuroprotection strategies during ECPR
Optimal timing and duration of support
Long-term quality of life outcomes

Practical Implementation: The Oysters (Hidden Gems)

Team Dynamics

The "ECMO Huddle": Brief team discussion before cannulation covering:

Primary indication and goals of care
Cannulation strategy and backup plan
Anticipated complications and responses
Family communication plan

Communication Strategies

The "30-Second Brief": Rapid situation update including:

Patient identifier and age
Primary pathology and duration
Current support and response
ECMO indication and urgency

Documentation Essentials

Pre-ECMO clinical status and interventions attempted
Decision-making rationale and team consensus
Technical details of cannulation
Initial ECMO parameters and patient response

Conclusion

Crash ECMO represents both the pinnacle of emergency critical care technology and one of its greatest challenges. Success requires the convergence of appropriate patient selection, technical expertise, institutional support, and multidisciplinary coordination. While not a panacea, emergency ECMO can provide meaningful survival benefit for carefully selected patients with reversible cardiopulmonary failure.

The key to successful crash ECMO programs lies not in the technology itself, but in the systematic approach to patient selection, rapid deployment, and meticulous post-cannulation care. As the field continues to evolve, emphasis must remain on quality improvement, outcome measurement, and the fundamental principle of "primum non nocere" – first, do no harm.

For the critical care practitioner, crash ECMO should be viewed as one tool in a comprehensive approach to severe cardiopulmonary failure. Like all powerful interventions, its greatest impact comes from knowing not just when and how to use it, but equally importantly, when not to.

References

Abrams D, et al. Emergency ECMO for cardiopulmonary resuscitation. Intensive Care Med. 2023;49(2):189-205.
Richardson AS, et al. ECMO Cardiopulmonary Resuscitation (ECPR), criteria for emergent ECMO activation and outcomes: A systematic review and meta-analysis. J Am Coll Surg. 2024;238(4):456-468.
Pavlushkov E, et al. Cannulation techniques for extracorporeal life support. Ann Transl Med. 2017;5(4):70.
Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators. Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA. 2009;302(17):1888-95.
ELSO International Summary Report. Extracorporeal Life Support Organization. January 2024. Available at: www.elso.org
Burkhoff D, et al. Hemodynamics of Mechanical Circulatory Support. J Am Coll Cardiol. 2015;66(23):2663-2674.
Schmidt M, et al. Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome. An international multicenter prospective cohort. Am J Respir Crit Care Med. 2019;200(8):1002-1012.
Combes A, et al. ECMO for severe ARDS: systematic review and individual patient data meta-analysis. Intensive Care Med. 2020;46(11):2048-2057.
Yannopoulos D, 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. Lancet. 2020;396(10265):1807-1816.

Conflicts of Interest

The authors declare no relevant conflicts of interest related to this review.

Funding

No specific funding was received for this work.

Thursday, September 18, 2025