St Emlyn’s Lesson Plans

ECMO in the ED: recognise the option and make the referral

Compare respiratory ECMO, circulatory support and ECPR, then practise the information needed for a specialist referral.

Higher Specialty Training · 60-minute session

For learners

Before: Allow about 23 minutes in total.

When we meet: We will discuss severe respiratory failure, a referral to an ECMO centre and the different requirements for ECPR.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Whiteboard, current service guidance, the written case and a blank handover sheet. No circuit, invasive simulation or invented ventilator settings are required.

Run: 60-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 23 minutes in total.

Core preparation

NHS England adult respiratory ECMO specification · About 10 minutes

Read the adult respiratory ECMO service scope, including the population covered and the role of specialist assessment.

https://www.england.nhs.uk/publication/extra-corporeal-membrane-oxygenation-for-respiratory-failure-in-adults/

Guy’s and St Thomas’ ECMO referral guidance · About 10 minutes

Read the referral page's required information, with attention to the details a colleague could gather while bedside care continues.

https://www.guysandstthomas.nhs.uk/referral-guide/extracorporeal-membrane-oxygenation-ecmo

Think about (allow 3 minutes): What care must continue at the bedside while a possible ECMO referral is discussed?

Picture the scene

An intubated patient with severe respiratory failure remains profoundly hypoxaemic. Someone asks about ECMO. What needs checking now, and what would the specialist team need to know?

By the end of the session

Explain the practical distinction between VV support for gas exchange, VA support for circulation and ECPR.
Recognise when severe potentially reversible respiratory failure merits early specialist discussion.
Prepare a referral and transfer plan while continuing safe local care and avoiding unrealistic promises.

After the session

With your critical-care team, verify the referral route you would actually use at 03:00 and record where colleagues can find it.

Optional further learning

You do not need to complete this before attending. The listening time is additional to the core preparation above.

Optional listening · 37 min 29 sec

St Emlyn’s Podcast: Ep 225 - A deep dive into ECMO with Andy Curry

Explore ECMO evidence, patient selection and the services needed to deliver it.

Listen to the episode

Search for this episode by title in MedPod Learn if you want to record your listening there.

Distinguish respiratory ECMO from ECPR and identify one question to ask the regional service. This 2023 talk reflects the evidence available then; compare it with the current references and referral criteria. It does not teach cannulation or establish treatment competence.

https://www.stemlynspodcast.org/e/ep-225-all-things-ecmo-with-andy-curry/

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 23 minutes in total.

Before learners arrive

Invite a critical-care clinician or confirm the session’s referral details with one. Check the current respiratory ECMO referral route and whether a separate cardiac/ECPR service exists locally.
Use the written respiratory scenario and the referral questions below. Bring a blank handover sheet; learners can mark information that still needs to be obtained. Additional numerical data are optional and should be checked with a critical-care colleague. Do not use real referral systems during the exercise.

Equipment: Whiteboard, current service guidance, the written case and a blank handover sheet. No circuit, invasive simulation or invented ventilator settings are required.

Setup: Run a tabletop exercise with roles for bedside lead, referral clinician, nurse coordinator and receiving specialist. Ask learners to keep the bedside plan visible while referral tasks occur.

If the preparation has not been completed

Use the seven-minute opening for shared preparation. Draw the heart and lungs, ask pairs to distinguish gas-exchange support from circulatory support, then read the specialist referral page together. Keep the referral requirements visible during the case. In the 30-minute version, use seven minutes here and reduce the respiratory case from 12 to 10 minutes; retain eight minutes for referral and five for the cardiac distinction and closing.

Suggested session plan

0–7 min — What ECMO can support. Use the simple circulation sketch to distinguish VV, VA and ECPR.
7–25 min — Respiratory failure case. Prioritise reversible checks and assemble a referral without abandoning local care.
25–37 min — Referral rehearsal. The receiving clinician asks for missing information and clarifies what acceptance would mean.
37–50 min — Cardiac-arrest variation. Expose the difference between a possible technology and an available functioning service.
50–55 min — Family explanation. Practise describing consultation, uncertainty and continuing care.
55–60 min — Close. Assign an owner to one identified local pathway gap.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

Severe hypoxaemia despite initial treatment

A previously independent adult has severe viral pneumonia and worsening hypoxaemia after intubation. Oxygenation remains poor despite immediate optimisation by the critical-care team. The ED is waiting for an ICU bed.

Add this information as the discussion develops:

Ask the group for the bedside checks and senior help needed before attributing every problem to refractory lung disease.
The critical-care consultant reports continuing severe oxygenation failure after rechecking the airway, equipment and agreed ventilation strategy. Ask which measurements and treatment details the receiving specialist will need.
The ECMO service asks about reversibility, duration of ventilation, comorbidity, organ function, imaging and treatments already attempted.

Ask the group:

What reversible equipment, airway and patient causes must be checked now?
Which form of support is being considered, and what does it not replace?
When should discussion begin relative to transfer and further deterioration?
Which information can be assembled while one clinician continues direct care?

Discussion notes

Points to draw out:

NHS England’s respiratory ECMO service concerns selected patients with severe potentially reversible respiratory failure managed through specialist centres and retrieval networks. Referral is a specialist assessment, not automatic acceptance.
VV ECMO principally supports gas exchange; it does not directly provide the same circulatory support as VA ECMO. The local critical-care team and centre should guide optimisation and suitability.
Prepare an accurate timeline and treatment response. The referral should include the underlying illness, physiological trend, ventilation, organ dysfunction, comorbidity, patient wishes where known and practical transfer issues.

Common misconceptions:

Waiting until irreversible collapse before considering discussion.
Treating a low saturation alone as a complete eligibility criterion.
Assuming ECMO cures the underlying disease.

For a more experienced group: Ask an experienced group how prolonged ventilation, bleeding risk or uncertain reversibility changes the discussion without turning those factors into improvised absolute exclusions.

Cardiac arrest and the wrong pathway

During a refractory cardiac arrest, someone suggests contacting the respiratory ECMO service and “putting the patient on bypass” while transport is arranged.

Add this information as the discussion develops:

Ask the group to identify which elements of this proposal are not established local practice.
Reveal that the hospital has no commissioned ECPR pathway or cannulation team on site.
Ask how the team should continue care and seek appropriate specialist advice without interrupting effective CPR.

Ask the group:

How does ECPR differ from referral for respiratory failure?
What must be in place for this to be a credible rescue option?
What is the risk of making ECMO the only focus of the resuscitation?
How would you explain the situation to the family without promising an unavailable treatment?

Discussion notes

Points to draw out:

RCUK 2025 describes ECPR as a possible rescue therapy for selected patients where a system to deliver it exists. It is not a generic next step for every prolonged arrest.
Continue high-quality conventional resuscitation and treatment of reversible causes. Referral, selection, cannulation, transfer and critical-care capacity require an established specialist system.
Ordinary cardiac bypass is not a routine bridge from any ED to an ECMO centre. Local capability and a specialist plan are essential.

Common misconceptions:

Allowing speculative transport or cannulation discussions to distract from effective resuscitation.
Confusing the respiratory ECMO referral portal with universal access to cardiac ECPR.

For a more experienced group: With a service lead, map a real regional ECPR pathway and identify decisions that must occur before arrest.

Important clinical points

Do not attempt extracorporeal procedures outside an established credentialed service.
Do not let referral delay treatment of reversible causes or conventional resuscitation.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

How do the roles of VV and VA ECMO differ?
Which information makes a referral useful?
Why is “ECMO exists” different from “ECPR is available here”?

Key teaching points:

ECMO provides support while the underlying illness is treated; suitability needs specialist assessment.
Respiratory ECMO and ECPR have different referral and delivery arrangements.
Continue local resuscitation and treatment while discussing referral.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

Selection is individual and service-dependent. Evidence, capacity and the patient’s goals influence decisions; avoid memorised universal thresholds or promises of acceptance.

If the discussion drifts

What can we improve here now, and what does the specialist team need to decide next?

For a more experienced group

Examine transfer risk, resource allocation and communication when specialist support is considered inappropriate, keeping the patient’s interests central.

A 30-minute version

30-minute option: mechanisms 5, respiratory case 12, referral 8, cardiac distinction and closing 5. Omit detailed eligibility debate.

Evidence and guidance

NHS England adult respiratory ECMO specification — 2019 specialist respiratory service specification; not a cardiac ECPR protocol.https://www.england.nhs.uk/publication/extra-corporeal-membrane-oxygenation-for-respiratory-failure-in-adults/
Guy’s and St Thomas’ ECMO referral guidance — Adult respiratory ECMO referral information and the national Signpost referral link.https://www.guysandstthomas.nhs.uk/referral-guide/extracorporeal-membrane-oxygenation-ecmo
RCUK 2025: Special circumstances — Selected ECPR rescue use where an implemented system exists; not a universal ED pathway.https://www.resus.org.uk/professional-library/2025-resuscitation-guidelines/special-circumstances-guidelines