Background: Hydrocarbon aspiration (HA) is well described as a cause of potentially fatal childhood poisoning. HA-induced acute respiratory distressed syndrome (ARDS) necessitates supportive cares, mechanical ventilation and may require rescue therapy with extracorporeal membrane oxygenation (ECMO). Published use of exogenous surfactant (ES) in this context is scant. Combined use of ES and ECMO has not been reported. We present a case of HA-induced ARDS successfully treated with ECMO and ES; response is documented with clinical, radiographic, and ECMO flow data. Case: A previously healthy 18-month-old boy presented to the Emergency Department via private car after witnessed aspiration of an oil-based cosmetic. Initial vital signs included respiratory rate 33, pulse 165 beats per minute, blood pressure 124/65 mmHg, and oxygen saturation 83% with bag valve mask ventilation. Physical exam showed a Glasgow Coma Scale score of 9, vomit in nares and oropharynx, tachypnea, grunting, and respiratory retractions. The patient was intubated and venous blood gas showed pH 6.98, pCO2 103 mmHg, pO2 25 mmHg, bicarbonate 24 mmol/L, and lactate 17 mmol/L. Chest x-ray showed bilateral pulmonary opacities. Venovenous ECMO was initiated due to continued hypoxemia despite advanced ventilator support. Sixty hours post-ingestion, 2 mL/kg of beractant (Survanta ®) surfactant was injected into bilateral lower lobes during bronchoscopy. After 24 hours, ECMO support needs decreased marginally and chest radiography improved, so another dose was administered. ECMO flow rate subsequently decreased from 88 to 61.1 ml/kg/min, sweep gas from 2.2 to 0.7 L/min, and fraction of inspired oxygen (FiO2) from 1.0 to 0.40 over the next 30 hours, indicating a marked improvement in pulmonary vascular resistance. ECMO support was discontinued on day 8 after a mediastinal hemorrhage. He was extubated on day 14 and had a complete recovery without neurologic sequalae. Case discussion: Hydrocarbons are organic compounds ubiquitous to products for cleaning, heating, and cooking. HA may lead to ARDS and death despite mechanical ventilation and ECMO. Proposed mechanisms of lung injury include disruption of the pulmonary surfactant layer and direct toxicity to lung tissue. ES's are approved for use in neonatal respiratory distress syndrome and are routinely stocked in Level I or II neonatal intensive care units. ES administration may be a useful adjuvant in cases of HA-induced ARDS. Conclusion: HA-induced ARDS is potentially fatal despite advances in treatment. This case of HA-induced ARDS treated successfully with ECMO and ES is the first to add ECMO flow data to support the overall response to therapy with ES.