## **CASE REPORT Open Access** ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds13049-025-01505-0/_page_0_Picture_3.jpeg) # Successful prehospital extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest - a case report Martin Breitkopf1\*, Christoph Wihler1 , Andreas Walther1 , Daniel Räpple2 , Gunter Kerst3 , Johannes Heymer2 and Matthias Ott2 ## **Abstract** **Introduction** Cardiac arrest in children necessitates a systematic approach, including Basic Life Support, Advanced Life Support and post-resuscitation care. Extracorporeal Cardiopulmonary Resuscitation offers a viable option for refractory cardiac arrest by providing hemodynamic support through extracorporeal circulation. While prehospital E-CPR in pediatric patients remains rare, two cases were reported in the Netherlands in 2023, demonstrating feasibility despite poor outcomes. We present the first documented case of pediatric prehospital E-CPR in Germany, conducted as part of the Klinikum Stuttgart extracorporeal membrane oxygenation program, showcasing its implementation in an urban setting. **Case presentation** A 16-year-old patient with known hypertrophic non-obstructive cardiomyopathy suffered a cardiac arrest following exertion. After unsuccessful conventional resuscitation, prehospital ECMO cannulation was initiated. Cannulation was performed without complications (15 French (23 cm arterial, 25 Fr 55 cm venous), achieving a flow rate of 4500 mL/min and stable hemodynamics. Echocardiography revealed a significantly thickened septal wall and impaired ejection function. During transport under ECMO support, spontaneous movements and breathing were observed, managed with sedation and lung-protective ventilation. **Outcome** Upon hospital admission, whole-body CT revealed only free intraperitoneal fluid consistent with anasarca, without vascular or cannulation-related complications. The patient was weaned from ECMO and extubated after 48 h, developing transient mild delirium and aspiration pneumonia, both resolved. An ICD was implanted for secondary prevention, and the patient was discharged neurologically intact (cerebral performance category 1). **Conclusion** Given the limited availability of pediatric E-CPR and the challenges of long transport distances, structured prehospital E-CPR programs with specialized teams may provide a viable solution for critically ill pediatric patients. **Keywords** Extracorporeal cardiopulmonary resuscitation, Pediatric, Cardiac arrest, Extracorporeal membrane oxygenation, Prehospital \*Correspondence: Martin Breitkopf m.breitkopf@klinikum-stuttgart.de Department of Anesthesiology, Klinikum Stuttgart, Stuttgart, Germany Internal Intensive Care Medicine, Klinikum Stuttgart, Stuttgart, Germany 3 Center for Congenital Heart Defects Stuttgart, Pediatric Intensive Care, Pulmonology and Allergology, Klinikum Stuttgart, Stuttgart, Germany ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds13049-025-01505-0/_page_0_Picture_14.jpeg) ## **Introduction** Cardiac arrest in children can arise from a wide range of underlying pathophysiological conditions, requiring a systematic and timely response to optimize outcomes. A structured approach to resuscitation, as outlined by resuscitation councils, involves a "chain of survival" framework. This begins with early recognition of cardiac arrest, followed by immediate initiation of high-quality bystander Basic Life Support, including defibrillation with an Automated External Defibrillator when indicated. Advanced Life Support measures are then employed to achieve the return of spontaneous circulation, with subsequent comprehensive post-resuscitation care to prevent secondary injury and improve survival rates. For children experiencing refractory cardiac arrest, Extracorporeal Cardiopulmonary Resuscitation offers a potential therapeutic option. This advanced technique involves the insertion of large-bore vascular sheaths into the common femoral artery and vein, enabling extracorporeal circulation through a portable heart-lung machine. By providing hemodynamic support, E-CPR maintains systemic perfusion and allows bridging to diagnostic evaluations and targeted therapies. Historically, E-CPR has been primarily utilized in cases of in-hospital cardiac arrest. However, recognizing the critical importance of minimizing low-flow time, there is growing interest in initiating E-CPR earlier in the resuscitation process, including prehospital settings. Although randomized controlled trials evaluating the efficacy of prehospital E-CPR in adults are not yet available, preliminary studies indicate that the approach is feasible, and its adoption in out-of-hospital care is steadily gaining momentum [\[1](#page-4-0)[–3](#page-4-1)]. In 2023, two cases of prehospital E-CPR in pediatric patients were published in the Netherlands. These cases demonstrated the feasibility of implementing E-CPR in a prehospital setting. The patients, aged 7 and 15 years, respectively, underwent E-CPR as part of their resuscitation. While the cases provided valuable insights into the practical application of prehospital E-CPR, the clinical outcomes in both instances were poor. These represent the first documented practical cases of prehospital E-CPR in pediatric populations, highlighting both the potential and the challenges associated with extending this advanced intervention to out-of-hospital scenarios [[4\]](#page-4-2). Furthermore, no additional pediatric cases of prehospital E-CPR have been described so far. Out-of-hospital ECMO in Germany was first reported by Arlt et al. in 2011 [\[5](#page-4-3)]. Since then, extracorporeal CPR has been increasingly discussed and structured at a national level [[6\]](#page-4-4). In Stuttgart, our structured ECMO program has been available since 2021, with prehospital ECMO initiation introduced in 2024. To date, no pediatric OHCA cases have been excluded in our program. We now present the first documented pediatric prehospital E-CPR case in Germany. This case was conducted as part of the Medical Intervention Car Project and the structured ECMO program of Klinikum Stuttgart in an urban setting. ## **Prehospital cannulation** E-CPR serves solely as a bridging intervention, with the time to definitive treatment of the underlying condition or to recovery. At Klinikum Stuttgart, a structured ECMO program enables the availability of a practical ECMO team 24/7 through close collaboration between intensive care medicine and anesthesiology. Following a standardized activation protocol, two senior physicians from these departments deploy with ECMO equipment to the scene using a specialized response vehicle as part of the Medical Intervention Car system. Both physicians are board-certified specialists with the additional qualification in intensive care medicine. They have successfully completed an ECLS training course and possess several years of in-hospital cannulation experience. In addition, they have undergone at least five specific out-of-hospital eCPR SOP training sessions. Both are highly experienced clinicians in clinical as well as prehospital emergency medicine. The criteria for prehospital cannulation include: - Age: greater than 12 years and less than 75 years. - Witnessed cardiac arrest. - Slow-flow time: less than 10 min. - Inability to reach an E-CPR-capable center within 40 min of collapse. This structured approach ensures timely initiation of E-CPR when prehospital conditions align with established criteria. Unilateral femoral cannulation is performed under ultrasound guidance, without an additional antegrade perfusion to avoid delays due to transport. The side of cannulation is chosen based on the operator's dominant hand. Following ultrasound-guided puncture and vessel confirmation using both sheaths, the first operator hands over the ultrasound device to the second operator. The second operator then advances the J-wire into the venous sheath and visualizes the wire in the inferior vena cava along the subxiphoid long axis. Subsequently, the cannulas are advanced after dilatation. Once the connection is established without air and the final arterial safety clamp is released, reperfusion begins at the extracorporeal life support system (1500 rpm for backflow prevention). Sweep gas flow is set at 1 L/min, increasing up to a maximum of 2 L/min [\[7](#page-4-5)]. In this setting, the CardioHelp system (Getinge, Maquet Cardiopulmonary GmbH, Germany) is used for extracorporeal life support. Different cannula sizes are **Table 1** Timeline cardiac arrest and chain of survival | Event | Arrival Firefighter | Arrival Ambu
lance & Physician | Arrival MIC
Team | Decision for
ecpr | Cannulation | Transport to
Ambulance | Arrival
on
ecpr
center | |-------|---------------------|-----------------------------------|---------------------|----------------------|-------------|---------------------------|---------------------------------| | 0 | +6 | +9 | +14 | +15 | +30 | +50 | +72 | always available in the vehicle. Specifically, we carry a 15 Fr / 23 cm arterial cannula, a 17 Fr / 23 cm arterial cannula, and a 19 Fr / 15 cm arterial cannula, as well as a 25 Fr / 55 cm venous cannula, a 25 Fr / 61 cm venous cannula, and a 23 Fr / 61 cm venous cannula. In addition, several special cannulas are available, including a 13 Fr / 15 cm Paquet arterial cannula, a 15 Fr / 23 cm single-stage Getinge arterial cannula, a 19 Fr / 55 cm multistage Medtronic venous cannula, and a 21 Fr / 55 cm multistage Getinge venous cannula. ## **Case presentation** A case of circulatory arrest was reported on a weekday at 14:04, involving a 16-year-old male patient with a height of 162 cm and a body weight of 52 kg. The event occurred in a subway train near a station located on the periphery of the city center. The response time from the Medical Intervention Car base was 14 min. Upon arrival of the ECMO team, the following clinical scenario was observed: The patient, who had a known history of hypertrophic cardiomyopathy, was running with friends to board the subway when he collapsed immediately after entering the train. Bystander cardiopulmonary resuscitation was initiated promptly, the subway was stopped, and an emergency call was made. After 6 min post-collapse, a professional firefighter crew, acting as first responders, arrived on scene. Advanced resuscitation efforts were commenced, including the application of an AED, which delivered a single shock and bag-valve-mask ventilation. Three minutes later, an ambulance crew and a physician-staffed emergency vehicle arrived, continuing resuscitation efforts. Intravenous access was established, and endotracheal intubation was performed, with an end-tidal CO₂ of 25 mmHg. The patient was defibrillated twice more, and intravenous epinephrine was administered according to the advanced cardiac life support algorithm. There was no spontaneous breathing, although the pupils were midto widely dilated following epinephrine administration. Five minutes later, the ECMO team arrived at the scene. During a team timeout, the available options were discussed. The transport time under mechanical CPR was estimated to be at least 30 min. The subway had not yet arrived at a station, which would have significantly delayed the technical rescue. The entire team assessed the situation and concluded that transport to an E-CPR center for pediatric ECMO was not feasible within the 40-minute window. Therefore, after considering all ECMO criteria positively, the decision was made to initiate prehospital cannulation. This was based on the known diagnosis of hypertrophic cardiomyopathy with expected poor output under mechanical CPR and ongoing pulseless electrical activity. The cannulation was performed as described, following the standard protocol of the structured ECMO program. In this case, the cannulation time was 17 min from the team's arrival on site (Table [1](#page-2-0)). A 15 Fr / 23 cm arterial cannula and a 25 Fr / 55 cm venous cannula were usede. The cannulation procedure was uncomplicated and was performed on the left side of the patient. After the decision to initiate ECPR, only mechanical chest compressions were continued during cannulation; no additional doses of epinephrine were administered. Ventricular fibrillation did not reoccur following ECMO initiation. A flow rate of 4500 mL/min was immediately achieved with the ECMO. Return of spontaneous circulation occurred immediately upon the onset of reperfusion. A sweep gas flow of 2 L/min was established using an external oxygen source. During cannulation, a second peripheral venous access was established according to the SOP. Additionally, 1.5 L of crystalloid full-electrolyte solution were infused, and a norepinephrine perfusor (5 mg/50 mL) was initiated at a flow rate of 5 mL/h. Additionally, 100 mg of hydrocortisone and 2 g of cefazolin were administered intravenously according to the standard operating procedure. The provisional securing of the cannulas is performed using cable ties sutured at the insertion site and the connection site. Further securing is conducted prehospital using only ECMO tube dressings. The insertion sites are temporarily covered with sterile dressings. Once the ECMO cannulas are secured, a further team time-out is performed [[7\]](#page-4-5). The position of the venous cannulas was subsequently checked via ultrasonography. Additionally, a transthoracic echocardiography was performed for further preliminary diagnostics. The TTE revealed a significantly thickened septum with a very narrow left ventricular outflow tract. The pump function appeared to be severely impaired. No pericardial effusion was observed. For transport, the patient was secured on a spine board using a spider harness. The mechanical CPR device remained with the patient during transport. All access points, including the endotracheal tube and ECMO tubing, were re-secured. The transport of the patient out of the subway, with the assistance of the firefighters already on site, proceeded without complications. During transport in the ambulance, spontaneous movements of the legs and the onset of spontaneous breathing were observed. Consequently, analgesia and sedation with 0.4 mg fentanyl and 200 mg propofol (administered fractionally) were required. Lung-protective ventilation was continued. Additionally, 200 mL of human albumin was administered for volume expansion. ## **Follow up and outcome** Upon hospital admission, a whole-body computed tomography scan was performed, revealing only free intraperitoneal fluid consistent with anasarca secondary to chronic heart failure. No evidence of vascular injury, cannulation-related complications, or hemorrhage was identified. Additionally, the initial cranial CT demonstrated no abnormalities. After 48 h, the patient was successfully weaned from extracorporeal membrane oxygenation and extubated. During the subsequent clinical course, the patient developed a transient mild delirium lasting three days, which resolved completely without long-term sequelae. An aspiration pneumonia was diagnosed and treated empirically with intravenous antibiotics. Oxygen therapy was required for an additional seven days to maintain adequate oxygenation. The patient was subsequently transferred to a stepdown ward, where an implantable cardioverter-defibrillator was implanted for secondary prevention of sudden cardiac death. The patient was discharged with a Cerebral Performance Category score of 1, indicating preserved neurological function without deficits. ## **Discussion** In general, there are only a few centers that offer ECPR for pediatric patients. Existing descriptions of ECPR typically apply to patients with a body weight as low as 20–30 kg, indicating a significantly limited nationwide availability. Consequently, in most cases, longer transport distances are required to transfer the patient to a center capable of providing ECPR. In the present case, a transport time—including travel distance—of over 40 min to reach an E-CPR-capable center can be assumed. In most cases, the use of mechanical CPR with resuscitation assistance, followed by rapid transport to a specialized center, should certainly be considered. In the present case, the patient's cardiomyopathy suggested reduced ejection fraction and a potentially poorer outcome. Furthermore, prehospital therapy-resistant resuscitation scenarios are relatively rare, and primary cardiac causes are even less common. Survival rates for pediatric in-hospital E-CPR reported in the literature vary between 30 and 50% [\[8–](#page-4-6)[13\]](#page-4-7). However, there is a lack of prehospital data on this topic. Mommers et al. published only two case reports involving patients aged 7 and 15 years, respectively. Both cases, however, had poor outcomes [[4\]](#page-4-2). The cannulation technique described by Mommers et al. is largely similar to the technique used in this case, involving visualization of the two guidewires in different vessels for position verification [\[4](#page-4-2)]. In both cases, cannulation is performed by a two-person team. Low-flow duration is a key determinant of outcomes and differs between ECPR and conventional CPR strategies across systems [[14\]](#page-4-8). To successfully perform prehospital E-CPR on a pediatric patient, a structured ECMO and E-CPR program for both adults and children was necessary in this case. Such a program requires a specialized team comprising members from anesthesiology, intensive care medicine, pediatric intensive care medicine, and internal intensive care medicine. Additionally, extensive team training and continuous optimization of workflows and equipment are crucial prerequisites. In the present case, the cannulation procedure was performed by a two-person team, utilizing a large backpack containing the ECMO system and an additional bag with various cannula sizes. Furthermore, the availability of a dedicated Medical Intervention Car enables immediate on-scene deployment of the experienced ECMO team, with activation initiated directly by the regional dispatch center. A defined fast-track admission process and interdisciplinary intensive care management after hospital arrival ensure seamless continuation of care. These structural and organizational components allowed for exceptionally rapid prehospital ECMO establishment shortly after cardiac arrest and likely contributed to the favorable neurological outcome observed in this case. ## **Conclusion** Given the limited availability of pediatric E-CPR and the challenges of long transport distances, structured prehospital E-CPR programs with specialized teams may provide a viable solution for critically ill pediatric patients. Further research and data collection on prehospital pediatric ECPR are needed to optimize outcomes and establish standardized protocols. #### **Abbreviations** AED Automatic external defibrillator CPC Cerebral performance category CPR Cardiopulmonary resuscitation E-CPR Extracorporeal cardiopulmonary resuscitation ECMO Extracorporeal membrane oxygenation Fr French mCPR Mechanical cardiopulmonary resuscitation MIC Medical intervention car SOP Standard operation procedure TTE Transthoracic echocardiography ## **Supplementary Information** The online version contains supplementary material available at [https://doi.or](https://doi.org/10.1186/s13049-025-01505-0) [g/10.1186/s13049-025-01505-0](https://doi.org/10.1186/s13049-025-01505-0). Supplementary Material 1 #### **Acknowledgements** Not applicable. #### **Author contributions** MB wrote the initial manuscript. All authors revised and reviewed the manuscript and the final manuscript. #### **Funding** Not applicable. #### **Data availability** Not applicable. ## **Declarations** #### **Ethics approval and consent to participate** This is a retrospective case report. There is no primary research intent. Therefore, approval of the ethics committee was not applicable. #### **Consent for publication** Informed consent was received for publication of the case. #### **Competing interests** The authors declare no competing interests. Received: 29 June 2025 / Accepted: 28 October 2025 ## **References** 1. Lamhaut L, Jouffroy R, Soldan M, et al. Safety and feasibility of prehospital extracorporeal life support implementation by non-surgeons for out-ofhospital refractory cardiac arrest. Resuscitation. 2013;84(11):1525–9. - 2. Lamhaut L, Hutin A, Puymirat E, et al. 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