Extracorporeal CPR for massive pulmonary embolism in a "hybrid 2136 emergency department"

Patients with massive pulmonary embolism (PE) have poor outcomes and their management remains challenging. An interventional radiology (IVR)-computed tomography (CT) system available in our emergency room (ER) allows immediate access to CT and extracorporeal membrane oxygenation (ECMO) with safe cannulation under fluoroscopy. We aimed to determine if initial treatment in this "hybrid ER" is helpful in patients with PE requiring extracorporeal cardiopulmonary resuscitation (ECPR).

The records of patients transferred to our hybrid ER between September 2014 and December 2017 who required ECPR for PE were reviewed.

Nine consecutive patients (median age 50 [range 30-76] years) with PE requiring ECPR were identified in our hybrid ER. Five (55.6%) had at least one risk factor for PE. Six (66.7%) experienced an out-of-hospital cardiac arrest and 3 (33.3%) had a cardiac arrest in the hybrid ER. Right ventricular overload was detected on electrocardiography and bedside transthoracic echocardiography in all cases. The median pH, lactate, PaCO₂, and HCO₃ values on arterial blood gas analysis in the hybrid ER were 7.01 (6.68-7.26), 14 (8-22) mmol l^-1, 44.7 (23.8-60.5) mmHg, and 10.4 (6.7-14.1), respectively. Four patients (44.4%) received monteplase for thrombolysis. No patient underwent surgical embolectomy. The median duration of ECMO was 69 (38-126) h. There were two ECMO-related bleeding complications. Eight patients (88.9%) survived and one died of post-resuscitation encephalopathy after weaning from ECMO.

A hybrid ER may be useful for initial management of massive PE requiring ECPR and may help to improve outcomes.