A critical-care update for teams involved in refractory respiratory failure, cardiogenic shock or selected cardiac arrest. It distinguishes VV ECMO, VA ECMO and ECPR, while emphasising early referral data, reversibility, frailty, downtime and bedside complications such as bleeding or limb ischaemia.

Severe sudden chest, back, flank or abdominal pain that is maximal at onset or migratory should interrupt an acute coronary syndrome pathway. Check pulses, blood pressures, neurological features and perfusion, then request dedicated aortic CTA rather than pulmonary embolism protocol imaging.

Severe limb pain with mild-looking skin is the surgical danger here. Choose this when cellulitis seems too small to explain tachycardia, hypotension, altered mental status or rapid progression, because early fluids, broad-spectrum antibiotics and surgical involvement cannot wait for crepitus or bullae.

Open this first after any collapse that seems settled. Confirm true transient loss of consciousness, check ECG, point-of-care glucose and pregnancy status when relevant, then treat no prodrome, exertional onset, palpitations or known heart disease as high-risk cues.

ED efficiency here means getting the right patient to the right next step at the right time, not moving faster for its own sake. The practical gain is the shift-start scan, the focused chart biopsy, and front-loading physician-dependent tasks before flow stalls.

The action is to check for weakness first, then look for visual loss, aphasia, or neglect. Start here because this brief episode turns suspected stroke into a fast triage decision and links a positive screen directly to CTA, thrombectomy thinking, and transfer planning.

A paediatric airway is not a smaller adult airway. Position early with a shoulder roll if the occiput flexes the neck, suction before landmarks disappear, pre-oxygenate aggressively, and plan a smaller tube and backup strategy before repeated attempts worsen oedema.

High-yield teaching needs restraint. A five-minute clinical lesson should deliver one usable framework, pearl or bias check that changes the next shift; once filler outruns action, polished education stops being practical.