Paramedic CAT (Critically Appraised Topic)

003 | ECMO for cardiac arrest due to hypothermia (submersion)

Author	Jennie Helmer	Date	2019-10-02
Reviewer	-	Edited	2020-10-22

Case Study

You respond to a patient who was ice-fishing and unfortunately, fell into the fishing hole.  The patient was able to hang on to the edge and did not go under water.  During rescue, he reportedly went unresponsive and pulseless.  Approximately 20 minutes passed before the patient was successfully recovered.  Once extricated, the patient was unresponsive and pulseless. The rescuers begin compressions, and the patient is brought to you with resuscitation ongoing.  

You and your team continue with resuscitation, and you contact CliniCall to discuss the possibility of ECMO (Extracorporeal Membrane Oxygenation) for this suspected hypothermic arrest.  The Paramedic Specialist conferences EPOS onto the call and they discuss the case with you.  The recommendation is that you transport this patient to an ECMO-capable hospital 45 minutes away.

Why did the EPOS/PS recommend you transport this suspected hypothermic-arrest patient to an ECMO facility, rather than staying on scene and managing your patient with standard cardiac arrest management?

PICO Question

“In pre-hospital patients experiencing cardiac arrest due to hypothermia, does ECMO versus standard CA management improve neurological survival?”

Population	Adult patient with hypothermic cardiac arrest
Intervention	ECMO (Extracorporeal Membrane Oxygenation)
Comparison	Standard AHA cardiac arrest management
Outcome	Improvement in Neurological Survival

Search Strategy

Pubmed: (“Prehospital Patients in Hypothermic Cardiac Arrest” OR “Accidental Hypothermia” OR “out-of-hospital Patients in Hypothermic Cardiac Arrest”) AND (“ECMO” OR “Extracorporeal Membrane Oxygenation” OR “ECLS” OR “Extracorporeal Membrane Oxygenation”) AND ( “CPR” OR “Standard Cardiac Arrest Management” OR “Cardiopulmonary Resuscitation”) AND ( “Survival” OR “ROSC” OR “Return of Spontaneous Circulation” OR “Neurologically Intact Survival”)

Search Outcome

29 Results (7 Relevant) on 2019-10-02

Clinical Bottom Line

These papers provide supportive evidence for the use of ECMO and is the rewarming strategy of choice for hypothermic cardiac arrest patients, and should be considered if feasible in under 6 hours.  One study (Paal, 2016) reported that ECMO has substantially improved survival and is the treatment of choice in the patient with unstable circulation or cardiac arrest.

Paramedics should contact CliniCall with any suspected Hypothermic Cardiac Arrest, and familiarize themselves with the BCEHS Handbook and Cardiac Arrest-Treatable Cause section.

Relevant Results

1. Brown D. Accidental Hypothermia Clinical Practice Guidelines for British Columbia.  2016 [cited 2019 Oct 02]. [LINK]
2. Danzl DF, ed. Accidental Hypothermia. in: Auerbach PS, Ed. Wilderness Medicine. 6th Ed. 2012. [LINK]
3. Lundgren P, Henriksson O, Naredi P, Björnstig U. The effect of active warming in prehospital trauma care during road and air ambulance transportation - a clinical randomized trial. 2011. [LINK]
4. Ohbe H, Isogai S, Jo T, Matsui H, Fushimi K, Yasunaga H. Extracorporeal membrane oxygenation improves outcomes of accidental hypothermia without vital signs: A nationwide observational study. 2019. [LINK]
5. Paal P, Brown D. Cardiac arrest from accidental hypothermia, a rare condition with potentially excellent neurological outcome, if you treat it right. 2014. [LINK]
6. Paal P, Brugger H, Strapazzon G. Accidental hypothermia. 2018. [LINK]