{"id":10238,"date":"2025-06-17T12:43:47","date_gmt":"2025-06-17T19:43:47","guid":{"rendered":"https:\/\/dhs.lacounty.gov\/emergency-medical-services-agency\/?page_id=10238"},"modified":"2025-07-01T14:49:58","modified_gmt":"2025-07-01T21:49:58","slug":"cases-from-the-field-may-june-2025","status":"publish","type":"page","link":"https:\/\/dhs.lacounty.gov\/emergency-medical-services-agency\/home\/emergi-press\/cases-from-the-field\/cases-from-the-field-may-june-2025\/","title":{"rendered":"Cases From The Field May June 2025"},"content":{"rendered":"

[vc_row][vc_column][vc_column_text css=””]<\/p>\n

Case Presentation<\/strong><\/h3>\n

DISPATCH INFO\/COMPLAINT: 62-year-old-male, Cardiac Arrest<\/p>\n

SCENE INFO: On arrival you find an unresponsive man on the floor of his kitchen with bystander, hands-only CPR in progress.<\/p>\n

HISTORY: Family reports patient was complaining of dizziness and indigestion after dinner. He left the living room to get a glass of water when the family heard him fall, found him unresponsive, and immediately initiated CPR. Family reports history of diabetes and hypertension but denies any history of heart disease.<\/p>\n

ASSESSMENT: Patient is unresponsive and apneic. Manual hands-only CPR is in progress. Patient\u2019s airway is open and appears patent. There is no obvious significant trauma. You quickly confirm he is pulseless.[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_tta_accordion][vc_tta_section title=”What are the initial steps in managing this patient?” tab_id=”1751403321690-7d330b89-bdc2″][vc_column_text css=””]You confirm the patient is in cardiac arrest and initiate management per Ref. No. 1210, Cardiac Arrest with high quality compressions and controlled ventilation. Initial rhythm is Ventricular Fibrillation (VF) and End-Tidal Carbon Dioxide (EtCO2) is 22 mmHg with compressions and Bag Mask Ventilation (BMV). He remains in VF despite receiving two defibrillations.<\/p>\n

As a witnessed arrest with initial and refractory shockable rhythm immediate bystander CPR this 62-year-old patient is an ideal ECPR candidate and should have expedited transport to an ECPR (Extracorporeal Cardiopulmonary Resuscitation, sometimes also referred to as ECMO) Center if one is available within a 30-minute transport time. Luckily your squad is equipped with a mechanical compression device (MCD), and your closest ECPR hospital is located only 10 minutes away. See the attachment below for MCG 1318, ECPR Patient Algorithm. This document and others related to ECPR centers and patient destinations will be available on the EMS website on and after July 1, 2025.[\/vc_column_text][vc_column_text css=””]You confirm the patient is in cardiac arrest and initiate management per Ref. No. 1210, Cardiac Arrest with high quality compressions and controlled ventilation. Initial rhythm is Ventricular Fibrillation (VF) and End-Tidal Carbon Dioxide (EtCO2) is 22 mmHg with compressions and Bag Mask Ventilation (BMV). He remains in VF despite receiving two defibrillations.<\/p>\n

As a witnessed arrest with initial and refractory shockable rhythm immediate bystander CPR this 62-year-old patient is an ideal ECPR candidate and should have expedited transport to an ECPR (Extracorporeal Cardiopulmonary Resuscitation, sometimes also referred to as ECMO) Center if one is available within a 30-minute transport time. Luckily your squad is equipped with a mechanical compression device (MCD), and your closest ECPR hospital is located only 10 minutes away. See the attachment below for MCG 1318, ECPR Patient Algorithm. This document and others related to ECPR centers and patient destinations will be available on the EMS website on and after July 1, 2025.[\/vc_column_text][vc_column_text css=””]<\/p>\n

\n

[\/vc_column_text][vc_column_text css=””]<\/p>\n

Which of the following should be performed prior to initiating transport to an ECPR center? Select ALL that apply.<\/strong><\/h6>\n

o Contact the base to request destination guidance
\no Perform at least two pulse checks
\no Place a mechanical compression device (LUCAS or AutoPulse)
\no Place an i-gel airway and confirm with waveform capnography<\/p>\n

Explanation: The 3rd and 4th options are the only correct answers. Potential ECPR candidates, should have a MCD and advanced airway placed prior to transport. Transport should be initiated as soon as the patient is determined to be in refractory VF per protocol (continued VF despite 2 defibrillations). In anticipation of transport, you should place the MCD after the 1st or 2nd shock, ensuring that you minimize any interruptions in CPR (for more information on MCD placement for piston-type devices, check out the EmergiPress videos earlier in this module). Medics should contact the ECPR center as early as possible but should not delay initiating transport to an ECPR center for a base order. Pulse checks are not indicated for patients in VF on rhythm check as this is not a perfusing rhythm.[\/vc_column_text][vc_column_text css=””]<\/p>\n

\n

[\/vc_column_text][vc_column_text css=””]<\/p>\n

\"Image

Image from LUCAS 3 Web Training Center: https:\/\/www.lucas-cpr.com\/web_training\/lucas3\/highlighted_topics\/<\/p><\/div>\n

Your agency uses the LUCAS, a piston-type mechanical compression device (MCD). You place a 2nd set of defibrillation pads anticipating possible vector change and place the LUCAS MCD according to manufacture specifications with the inferior edge of the \u201csuction cup\u201d aligned with the inferior border of the sternum and compressions are initiated.<\/p>\n

 <\/p>\n

[\/vc_column_text][vc_column_text css=””]<\/p>\n

\"Photo

Photo courtesy of Los Angeles County Fire Department<\/p><\/div>\n

 <\/p>\n

An i-gel supraglottic airway (SGA) is placed and EtCO2 is 28 mmHg with normal box-like waveform after LUCAS and i-gel placement. The patient is moved to the gurney and into the ambulance to initiate transport.<\/p>\n

During your next rhythm check, you notice that the EtCO2 has decreased from 28 mmHg to 18 mmHg.<\/p>\n

 <\/p>\n

 <\/p>\n

[\/vc_column_text][vc_column_text css=””]<\/p>\n

\n
Which of the following are possible causes of this decrease in EtCO2? Select ALL that apply.<\/strong><\/h6>\n

o EMT is ventilating too quickly (hyperventilation)
\no LUCAS piston has migrated and is no longer compressing in an optimal location
\no Patient has unrecoverable cardiac arrest
\no Previously administered epinephrine is \u201cwearing off\u201d<\/p>\n

Explanation: The 1st and 2nd options are the correct answers. While EtCO2 <10 after 20 minutes of high-quality CPR has been associated with poor prognosis, this must be considered within the context of other factors. This patient is less than 15 minutes into their cardiac arrest and does not meet criteria for futility of resuscitation. Epinephrine is not expected to effect EtCO2 in a patient with ongoing VF arrest. Read on for why a sudden decrease in EtCO2 should prompt evaluation for inadvertent hyperventilation and LUCAS\/AutoPulse migration.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”Interpreting EtCO2 in Cardiac Arrest Management” tab_id=”1751403321703-44be1f01-0717″][vc_column_text css=””]The measurement of EtCO2 is based upon both perfusion and ventilation. Whenever you identify a decreasing EtCO2 you should evaluate both ventilation and perfusion.<\/p>\n

Ventilation<\/strong><\/p>\n

\u00b7 Ensure that the person providing ventilations continues to ventilate at a ratio of 1 breath every 6 seconds through an advanced airway
\n\u00b7 Confirm advanced airway is in appropriate position and has not become displaced<\/p>\n

Perfusion<\/strong><\/p>\n

\u00b7 Ensure continued high-quality compressions with good recoil
\n\u00b7 Confirm correct position of the MCD. Is the MCD suction cup aligned with the inferior border of the sternum?<\/p>\n

EtCO2 is the most objective way to assess the quality of compressions. Palpation of femoral pulses during compressions is not adequate to assess for quality of compressions. Since there are no valves in the IVC, retrograde (backwards) blood flow can cause pulsations in the femoral vein that may imitate a weak pulse despite poor forward flow. While palpation of the carotid pulse is more sensitive for detecting a pulse, its presence does not indicate effective organ perfusion. EtCO2 is significantly more accurate and has been recommended to monitor resuscitation in ACLS guidelines since 2010.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”The Case Continues” tab_id=”1751404544085-8d65746c-779a”][vc_column_text css=””]After verifying that the EMT is ventilating at a rate of 1 breath every 6 seconds, the EtCO2 remains at 18 mmHg. You notice that the piston suction cup is now centered over the inferior border of the sternum. The LUCAS piston has migrated! It is no longer providing high quality compressions and perfusion has likely been reduced for the past several minutes.[\/vc_column_text][vc_column_text css=””]<\/p>\n

\n
How could this prolonged-low flow state have been avoided?<\/strong><\/h6>\n

A. Drawing a circle around the suction cup after initial placement
\nB. Using the neck strap provided with the LUCAS appropriately
\nC. Monitoring the EtCO2 and CPR bar (where available) every 20-30 seconds
\nD. All of the above<\/p>\n

Explanation: The correct answer is \u201cAll of the above\u201d. Continue reading for more explanation<\/em><\/p>\n

\n

[\/vc_column_text][vc_column_text css=””]<\/p>\n

\"LUCAS

LUCAS piston positioned too high on chest — above the nipple line.<\/p><\/div>\n

Piston migration, otherwise known as \u201cMCD walk\u201d is being recognized with increasing frequency. In this phenomenon, patient movement for procedures\/transport, the body movements during defibrillation, and the act of compression itself causes the piston to gradually shift from its original position, slowly \u201cwalking\u201d up towards the nipples or down towards the belly button\u2013 off the optimal compression point over the left ventricle.<\/p>\n

The \u201cwalk\u201d or migration of the piston is revealed by a gradual decrease in the EtCO2. If your monitor displays CPR \u201cbars\u201d for each compression, and your agency has chosen to keep the puck in place during LUCAS use, you may also see the size of these bars decrease as the piston wanders to an area with less distance to compress.[\/vc_column_text][vc_column_text css=””]<\/p>\n

\"Image

Image from Tuolomne County EMS: https:\/\/www.tuolumnecounty.ca.gov\/DocumentCenter\/View\/8464\/S11-Chest-Compression-Systems<\/p><\/div>\n

The manufacturer of the LUCAS recommends application of the neck strap, termed the \u201cLUCAS Stabilization Strap\u201d, as an integral part of placing the LUCAS to secure the device in position. It should be released and then reconnected if you need to adjust the position of the suction cup. However, the stabilization strap alone will not fully prevent MCD walk and so persistent monitoring is important.<\/p>\n

In addition, the LUCAS 3 instructor\u2019s guide now refers to the practice of tracing a line on the chest at the edge of the suction cup to monitor for movement \u2013 if the suction cup moves outside of its markings, it must be repositioned.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”Can this happen with non-piston MCDs?” tab_id=”1751405948906-cef0b94c-13f1″][vc_column_text css=””]MCD walk has not specifically been reported with use of the AutoPulse (which uses a load-distributing band to compress the heart, rather than the piston technology of the LUCAS). However, several AutoPulse-associated injuries, including pneumothorax and liver laceration, are thought to have resulted from placement of the load-distributing band lower on the patient\u2019s chest than is recommended. EMS clinicians using the AutoPulse should visually monitor the position of the band, and the EtCO2 value, and readjust positioning if either of these should move lower during care or transport.<\/p>\n

It is important to note that initial placement of the LUCAS or AutoPulse should be assessed by both palpation of the carotid pulse during compressions AND initial EtCO2.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”Why does it matter where the MCD is placed?” tab_id=”1751405988034-aa8dbddb-1f97″][vc_column_text css=””]While the 2015 and 2020 AHA guidelines recommend performing compressions with the hands placed on the lower half of the sternum, some authors suggest that the ideal placement for many adults is below the nipple line and to the left of the sternal midline. Performing compressions as high as the nipple line may compress the ascending aorta, blocking blood exiting the heart in as many as 80% of cardiac patients. [Click here for a great article on optimal LUCAS use from the Journal of EMS online]. Yet every patient is different. Thus, after the LUCAS is placed in the standard location, at the center of the sternum with the inferior edge of the suction cup just above the inferior sternal border, the EtCO2 should be assessed and carotid pulse palpated during compressions.<\/p>\n

If EtCO2 is lower than expected (and especially if it is lower than what was noted with manual compressions), consider adjusting the LUCAS piston slightly to the left (though still on the sternum), and slightly lower while attempting to ensure there is no pause in compressions longer than 10 seconds. Ensure that the piston stays on the sternum and is not compressing the abdomen as this may cause liver or splenic injury.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”Conclusion” tab_id=”1751406026972-291d769a-d7f2″][vc_column_text css=””]After you adjust the LUCAS suction cup to the original position the EtCO2 returns to 28 mmHg. The stabilization strap is secured, and a line is drawn on the patient\u2019s chest along the inferior border of the suction cup. The LUCAS is noted to migrate again during the transport, but with your astute observation and frequent assessment of capnography, you note it quickly and correct. The patient arrives at the ED after a 12-minute transport having received a total of 8 defibrillations, 3 doses of epinephrine and a total of 450 mg of Amiodarone while in your care per Ref No 1210, Cardiac Arrest. He is transferred from the EMS to ED LUCAS with minimal interruption in CPR (less than 8 seconds) by EMS and ED personnel who watched and practiced the procedure demonstrated in the video portion of this month\u2019s EmergiPress. He remains in VF and is determined to be an appropriate candidate for ECPR. The patient is cannulated in the ED and placed on the ECMO machine before being taken for cardiac catheterization.<\/p>\n

The patient is discharged alive and neurologically intact from the hospital 2 weeks later.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”Learning Points” tab_id=”1751406067287-8ff919c7-213a”][vc_column_text css=””]<\/p>\n

    \n
  • \u00a0Patients \u226475 years old with an initial and refractory shockable rhythm who are within 30 minutes transport time to an ECPR center should undergo expedited transport from the scene.<\/li>\n
  • \u00a0Prior to initiating transport, a mechanical compression device (MCD) and advanced airway (i-gel or endotracheal intubation) should be placed and confirmed.<\/li>\n
  • Use waveform EtCO2 to evaluate whether the MCD is properly positioned and quality compressions are maintained. In particular, the location of the LUCAS piston and suction cup must be monitored. The initial starting position should be in the lower third of the sternum, with the lower edge of the suction cup aligned with the inferior sternal border.<\/li>\n
  • \u00a0If EtCO2 is lower than expected or decreases during compressions, evaluate for hyperventilation, advanced airway displacement, and\/or poor perfusion due to device migration (aka \u201cMCD walk\u201d) or tiring manual compression. Correct these quickly as possible to limit the length of the \u201clow-flow\u201d state.<\/li>\n<\/ul>\n

    [\/vc_column_text][\/vc_tta_section][\/vc_tta_accordion][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text css=””]References<\/strong><\/p>\n

    For a bit of light reading, or to check the facts, check out these resources which were used in developing this Case of the Month:<\/p>\n

    Giraud R, Siegenthaler N, Schussler O, Kalangos A, M\u00fcller H, Bendjelid K, Banfi C. The LUCAS 2 chest compression device is not always efficient: an echographic confirmation. Ann Emerg Med. 2015 Jan;65(1):23-6. doi: 10.1016\/j.annemergmed.2014.01.020. Epub 2014 Feb 13. PMID: 24530109. LUCAS\u00ae 3 Instructions for Use, accessed 5\/28\/2025 at https:\/\/www.lucas-cpr.com\/files\/5496926_100925-01%20Rev%20E%20LUCAS%203%20IFU%20EN_lowres.pdf<\/p>\n

    LUCAS\u00ae 3, v3.1 Instructor guidebook: Classroom and hands-on training, Accessed 5\/28\/2025 at https:\/\/www.stryker.com\/content\/dam\/stryker\/ems\/resources\/training-materials\/lucas_3_instructor_guidebook.pdf<\/p>\n

    Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S729-67. doi: 10.1161\/CIRCULATIONAHA.110.970988. Erratum in: Circulation. 2011 Feb 15;123(6):e236. Erratum in: Circulation. 2013 Dec 24;128(25):e480. PMID: 20956224.<\/p>\n

    Panchal AR, Bartos JA, Caba\u00f1as JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM; Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161\/CIR.0000000000000916. Epub 2020 Oct 21. PMID: 33081529.<\/p>\n

    Wik L. Optimal Use of Automated Mechanical Chest Compression Devices During Cardiopulmonary Resuscitation. Journal of EMS. 2021 Jul 7. Accessed 6\/10\/2025 at: https:\/\/www.jems.com\/ems-operations\/ems-equipment-gear\/optimal-use-of-automated-mechanical-chest-compression-devices-during-cardiopulmonary-resuscitation\/[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_separator css=””][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text css=””]Authors: Shira Schlesinger, MD MPH, Kelsey Thompson, MD<\/em>[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"

    [vc_row][vc_column][vc_column_text css=””] Case Presentation DISPATCH INFO\/COMPLAINT: 62-year-old-male, Cardiac Arrest SCENE INFO: On arrival you find an unresponsive man on the floor of his kitchen with bystander, hands-only CPR in progress. HISTORY: Family reports patient was complaining of dizziness and indigestion after dinner. He left the living room to get a glass of water when the […]<\/p>\n","protected":false},"author":38,"featured_media":0,"parent":1611,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-templates\/template-basic-page.php","meta":{"_oasis_is_in_workflow":0,"_oasis_original":0,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":"","_links_to":"","_links_to_target":""},"categories":[],"tags":[],"class_list":["post-10238","page","type-page","status-publish","hentry"],"yoast_head":"\nCases From The Field May June 2025 - Emergency Medical Services Agency<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/dhs.lacounty.gov\/emergency-medical-services-agency\/home\/emergi-press\/cases-from-the-field\/cases-from-the-field-may-june-2025\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Cases From The Field May June 2025 - Emergency Medical Services Agency\" \/>\n<meta property=\"og:description\" content=\"[vc_row][vc_column][vc_column_text css=””] Case Presentation DISPATCH INFO\/COMPLAINT: 62-year-old-male, Cardiac Arrest SCENE INFO: On arrival you find an unresponsive man on the floor of his kitchen with bystander, hands-only CPR in progress. 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HISTORY: Family reports patient was complaining of dizziness and indigestion after dinner. He left the living room to get a glass of water when the […]","og_url":"https:\/\/dhs.lacounty.gov\/emergency-medical-services-agency\/home\/emergi-press\/cases-from-the-field\/cases-from-the-field-may-june-2025\/","og_site_name":"Emergency Medical Services Agency","article_modified_time":"2025-07-01T21:49:58+00:00","og_image":[{"width":318,"height":159,"url":"https:\/\/dhs.lacounty.gov\/emergency-medical-services-agency\/wp-content\/uploads\/sites\/51\/2025\/06\/source_LUCASalignedwithinferiorsternalborder.jpg","type":"image\/jpeg"}],"twitter_card":"summary_large_image","twitter_misc":{"Est. reading time":"11 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/dhs.lacounty.gov\/emergency-medical-services-agency\/home\/emergi-press\/cases-from-the-field\/cases-from-the-field-may-june-2025\/","url":"https:\/\/dhs.lacounty.gov\/emergency-medical-services-agency\/home\/emergi-press\/cases-from-the-field\/cases-from-the-field-may-june-2025\/","name":"Cases From The Field May June 2025 - 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