Emergency Medical Services Physician-Led Activation for Extracorporeal Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation (ECPR) has been associated with improved survival among out-of-hospital cardiac arrest (OHCA) patients with refractory ventricular tachycardia (VT) or ventricular fibrillation (VF). However, the ideal approach for integrating an ECPR program within an emergency medical services (EMS) agency and local hospitals is unknown. The objective of this study was to investigate an EMS physician-led prehospital ECPR program. METHODS: We conducted an observational cohort study of a locally developed, EMS physician-led prehospital ECPR activation protocol within a third-service EMS agency serving an urban population and a large, academic tertiary care center in North Carolina between May 1, 2024 and May 19, 2025. Adult OHCA patients aged 18 to 60 years with non-traumatic, witnessed cardiac arrest, receipt of bystander cardiopulmonary resuscitation, and an initial rhythm of VT or VF or automated external defibrillator advised shock, refractory to three defibrillation attempts were eligible for ECPR activation. For eligible patients, paramedics consulted an online EMS physician, who could activate ECPR with subsequent intra-arrest transport to the hospital for cannulation. The primary outcome was the proportion of patients with non-traumatic OHCA who were eligible for ECPR. Secondary outcomes included the proportion of eligible patients with ECPR activation, cannulation, survival to hospital discharge, and cerebral performance category (CPC). Data were abstracted from the EMS and hospital electronic medical records. RESULTS: During the one-year study period, 347 patients experienced non-traumatic OHCA, of whom 4.3% (15/347) were eligible for ECPR. These 15 patients had a median age of 53 years (interquartile range 45-60), 80% (12/15) were male, and 60% (9/15) were non-White. The ECPR protocol was activated in 66.7% (10/15). Among these, cannulation occurred in 50% (5/10). Survival to hospital discharge occurred in 40% (4/10) of the ECPR activation group, all with CPC of 1. Among those eligible patients without ECPR activation, 60% (3/5) survived to discharge with 1 having a CPC of 1. CONCLUSIONS: The EMS physician-led ECPR protocol identified a subset of eligible patients for ECPR activation and resulted in successful cannulation of 5 patients. Further investigation in a larger, multi-system study is needed to determine the impact on patient-centered outcomes.