Clinicians
This page provides clinical information and resources for healthcare professionals, especially NSW Ambulance Paramedics, involved in or seeking to understand the PRECARE trial and ECPR.
Scroll below for clinical FAQs, or click to download the .zip of clinical resources outlining patient selection criteria, clinical infographics, and operational checklists used within the PRECARE trial. You can also listen to the latest episode of the Sydney HEMs Debrief Podcast, or click on the Podcast to access previous episodes.
FAQs
What is PRECARE?
PRECARE is a pre-hospital study assessing the feasibility of ECMOCPR (ECPR) being performed by retrieval specialists on eligible patients who are in refractory cardiac arrest. The study team (ECMO-1) is made up of one CCP and two retrieval consultants working with paramedic crews. The aim of ECPR is to use ECMO to provide oxygen and blood flow to the brain and other vital organs whilst the heart is in cardiac arrest. This will effectively buy the patient time to get to hospital with their vital organs well perfused and allow the cause of the cardiac arrest to be treated.
What days and where does PRECARE operate?
ECMO-1 is operating Mondays, Tuesdays, and Fridays (0700-1900hrs).
The car (ECMO 1) is based at Homebush (near the SOC) to best service the whole of metropolitan Sydney. Dispatch will occur if it is reasonable the team will reach the patient within 45 minutes of collapse. Current metrics anticipate the car will reach 90% of the greater Sydney metropolitan area by being based out of this location in Homebush.
What are the eligibility criteria?
Age <70
Witnessed arrest (witnessed by bystanders, family, clinicians – confirmation this is a recent arrest)
Immediate bystander CPR (within 5 minutes of arrest appropriate)
Initial rhythm shockable OR non-shockable PEA – VF/VT or PEA, just not asystole.
No significant comorbidities
What happens if the patient goes into asystole before ECMO-1 arrives?
Keep the PRECARE team coming. The rhythm of interest is the initial rhythm. If the first rhythm is VF/VT or PEA, the patient may still be eligible as it increases the likelihood that the patient will benefit from ECMO as a bridge to revascularisation/ intervention. Furthermore, the PRECARE team is a clinically experienced team with advanced interventions which may benefit certain cardiac arrest patients beyond ECPR. The ECMO team also have a Out-Of-Hospital Cardiac Arrest (OHCA) clinician who works closely with dispatch, if there is a case more suitable the OHCA clinician will liaise with the team and ensure the most clinically appropriate patients are prioritised. The best thing paramedics can do for the ECMO team is give information from scene.
What happens if the patient gets a ROSC before ECMO-1 arrives?
Continue your normal resuscitation and post ROSC care but keep the PRECARE team coming. On the arrival of the team, a discussion can be had between the treating crew and the PRECARE team regarding the sustainability and stability of the ROSC. Based on this two-way discussion, a decision will be made regarding whether the PRECARE team will travel with the patient to hospital. As always, if there is another case more suitable for the ECMO team the OHCA clinician will liaise and ensure the most clinically appropriate patients are prioritised.
What is ECMO ALS?
ECMO ALS is a variation on standard ALS that will occur when the ECMO (PRECARE) team decides the patient is eligible for ECPR. In ECMO ALS there is
- No more defibrillations (COACHED cycles)
- No more adrenaline
The patient will only transition to ECMO ALS if they have been refractory to conventional treatment (> 3 defibrillations and > 15min resuscitation) and only in the presence of and in consultation with the PRECARE team.
ECMO ALS is all about optimising the conditions for a QUICK and successful ECMO cannulation to achieve oxygen and flow to the brain.
If patients have not responded to defibrillation after >3 shocks the likelihood of achieving a sustained ROSC diminishes, the best chance of patient survival becomes performing ECPR as quickly as possible, COACHED cycles and defibrillation slow down the process
Adrenaline causes significant vasoconstriction making it harder to cannulate the femoral artery and reducing the success rate of successful ECPR cannulation
ECMO ALS is all about optimising the conditions for a QUICK and successful ECMO cannulation to achieve oxygen and flow to the brain.
What happens if ECMO-1 arrives on scene and the patient is not eligible for ECMO?
The PRECARE team will be there to support the paramedic crew if they request support, but the paramedics are encouraged to continue with their management and team leadership as per the Clinical Practice Guidelines. Any interventions or medical care provided by the PRECARE team will be in consultation with the treating paramedics and aimed to augment their care.
Which hospital will these patients be transported to?
The ECMO-1 team does not have transport capacity, so the patients will always be transported in the treating team’s ambulance. The destination hospitals for ECMO patients will be either St Vincents, Royal Prince Alfred, or Westmead Hospital depending on availability and distance. If a patient is not placed on ECMO however interventions have been undertaken by the team, the hospital destination will be a clinical discussion between the team and treating paramedics.
How can we as Paramedics keep these scenes calm and ordered?
These will be busy scenes and the first couple of minutes after ECMO-1 arrival is likely to feel intense. We will be doing our best to minimise this, but we are very aware that time is of the essence.
The team leader can expect to receive both support and direction from the CCP with reference to the ECMO specific skills, but you will be expected to independently manage the patient clinically as you normally would.
The handover from paramedics to the CCP is a handover of information, not a handover of care. The handover should be brief and focussed; referencing the eligibility criteria only.
The most important thing to remember is that the priority for the paramedic team is to continue good resuscitation. Apart from making an early report advising of the PRECARE criteria, we want you to continue business as usual unless we advise you to move to ECMO ALS after we arrive on scene.
Establishing a team leader with good, calm leadership skills will help keep a sense of calm.
How should we prepare to extricate these patients?
Extrication is situation specific. Experience has shown benefit in having a Stokes Litter and as such, consideration should be given to organising rescue agencies or SOT paramedics. After ECMO cannulation is complete and secured, the sterile field can be removed, this will help simplify the process. The paramedics must assist with driving the extrication process as they normally would and can seek clarification from the CCP as required.
PRECARE 