Extracorporeal membrane oxygenation (ECMO) is an established therapy that supports a patient in respiratory or cardiopulmonary failure to recovery, transplant, or durable mechanical support. Prompt referral by the emergency clinician for ECMO in appropriate patients is necessary for optimal outcomes.

This narrative review discusses the mechanisms by which ECMO stabilizes respiratory or cardiopulmonary failure, the indications for urgent ECMO referral, and the logistical requirements for initiating ECMO in the Emergency Department (ED) with a focus on the emergency clinician.

Indications for veno-venous (VV)-ECMO referral include refractory hypoxemia or hypercapnia in acute respiratory failure despite maximal conventional therapies. Veno-arterial (VA)-ECMO indications include cardiogenic shock and extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest, which require rapid initiation to prevent further decompensation and improve neurologic outcomes. The ED clinician is uniquely positioned to affect the timeliness of referrals and transport of the patient to an ECMO center if necessary.

This narrative review will help the emergency clinician better understand the role, management, and indications for referral among patients who may be candidates for ECMO as well as provide practical guidance to the emergency clinician in facilitating cannulation in the ED.