Emergency department extracorporeal membrane oxygenation: Current concepts, systems-based implementation, and future directions

Extracorporeal membrane oxygenation (ECMO) has emerged as a time-critical resuscitative strategy for carefully selected patients with refractory cardiac arrest and other reversible causes of circulatory or respiratory failure. As the role of emergency department ECMO (ED ECMO) continues to expand, emergency physicians have become integral members of multidisciplinary extracorporeal resuscitation teams. This review aims to summarize the current evidence on ED ECMO while highlighting practical considerations for program implementation, workflow optimization, and future directions. This invited narrative review synthesizes contemporary evidence regarding the indications, patient selection, cannulation strategies, pericannulation management, and postcannulation physiological challenges of ED ECMO, with particular emphasis on extracorporeal cardiopulmonary resuscitation. In addition to published literature, practical aspects of ED ECMO implementation, including multidisciplinary team organization, operational governance, workflow optimization, quality metrics, and institutional experience, are discussed. Emerging concepts such as artificial intelligence-assisted decision support, digital twin-enabled system modeling, and regional implementation strategies are also reviewed. Current evidence indicates that successful ED ECMO depends not only on technical proficiency but also on timely patient selection, standardized protocols, efficient multidisciplinary coordination, and optimized operational systems. Contemporary implementation frameworks emphasize integrated governance, continuous quality improvement, and structured performance metrics to enhance clinical effectiveness. Emerging digital technologies, including artificial intelligence and systems modeling, may further improve patient selection, operational efficiency, and program scalability. ED ECMO should be regarded as a comprehensive, systems-based resuscitation strategy rather than a standalone rescue procedure. Future progress is likely to depend on the integration of evidence-based patient selection, standardized workflows, multidisciplinary collaboration, intelligent operational systems, and continuous quality improvement. The development of regional ED ECMO networks supported by robust emergency medical service infrastructure may improve timely access to extracorporeal resuscitation and optimize patient outcomes.