Extracorporeal cardiopulmonary resuscitation (ECPR) is characterized by rapid cannulation and initiation of extracorporeal membrane oxygenation (ECMO) during cardiac arrest [1]. ECPR provides end organ perfusion and oxygen delivery during refractory cardiac arrest but is a complex and resource-intensive resuscitation therapy due to interdependence of dedicated ECPR personnel, equipment, and clinical judgment [2]. The use of ECPR has increased during the past decade but intra- and inter-institutional variability in practice has hindered the development of consensus based guidelines on best practices [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]]. The preponderance of data supports the use of ECPR for pediatric cardiac surgical patients who experience in-hospital cardiac arrest and in pediatric patients who experience cardiac arrest within an intensive care unit (ICU) environment. Although North American data suggest approximately 5000 pediatric patients experience non-traumatic, out-of-hospital cardiac arrest (OHCA) annually, data related to the use of ECPR in this patient population remains limited [3,[11], [12], [13], [14]]. Data from the Extracorporeal Life Support Organization (ELSO) international registry suggests that children represent only 3% of patients who receive ECPR for OHCA [15,16]. Furthermore, published data about the use of ECPR for children who experience cardiac arrest in the ED (EDCA) is unavailable [16,17]. Consequentially, children who experience OHCA or profound illness leading to cardiac arrest in an emergency department remain largely understudied.

The aim of this study was to characterize pediatric patients who receive ECPR for refractory OHCA or EDCA and to examine variation in the location of ECPR cannulation among those with OHCA and EDCA. Our secondary aims were to compare cardiac arrest and pre-ECPR characteristics for patients who experience either OHCA or EDCA by location and timing of ECPR cannulation, as well as to investigate the association of cardiac arrest location and ECPR cannulation location with outcomes of mortality. We hypothesized that pediatric patients who undergo ECPR cannulation for OHCA would have higher mortality compared to those with EDCA, and that patients cannulated outside of the emergency department (ED) would have higher mortality comparted to patients who are cannulated in the ED.