Head-up CPR: BLS Systematic Review

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ILCOR staff

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This Review is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final Review will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: (none applicable)

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: (none applicable)

CoSTR Citation

Insert citation for ILCOR.org posting of CoSTR

Wigginton J, Olasveengen TM, O’Neil B, Berg K, Kudenchuck P, Ristagno G, …, Morley PT -on behalf of the International Liaison Committee on Resuscitation Basic and Advanced Life Support Task Forces.

Head-up CPR for Cardiac Arrest in Adults Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic and Advanced Life Support Task Force, 2021 Feb 15th. Available from: http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of conducted by Basic Life Support Task Force members Jane Wigginton and Theresa M. Olasveengen, with the involvement of clinical content experts from both Basic Life Support and Advanced Life Support Task Forces. These data were taken into account when formulating the Treatment Recommendations.


The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults in any setting (in-hospital or out-of-hospital) with cardiac arrest.

Intervention: Head-up CPR.

Comparators: Standard or compression only CPR in the supine position.

Outcomes: Survival to hospital discharge with good neurological outcome and survival to hospital discharge were ranked as critical outcomes. Return of spontaneous circulation (ROSC) was ranked as an important outcome.

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to January 22nd, 2021.

“Bias was assessed per comparison rather than per outcome, since there were no meaningful differences in bias across outcomes.”

Consensus on Science

For the important outcome of survival to hospital admission we identified very-low-certainty evidence (downgraded for serious risk of bias) from one observational (before/after) study (Pepe 2019)(1) enrolling 1835 adult out-of-hospital cardiac arrest, which showed improved return of spontaneous circulation (ROSC) to hospital arrival in patients receiving -20°head-up CPR compared to standard care (RR, 1.90; 95%CI, 1.61–2.26; P <0.001; absolute risk reduction [ARR], 16.1%; 95% CI, 20.0% to 12.2%, or 161 more patients/1000 survived with the intervention [95% CI, 109 more patients/1000 to 225 more patients/1000 survived with the intervention]). Notably, both head-up and standard resuscitation in this study were bundled with mechanical CPR and use of an impedance threshold device. In addition, head-up CPR, but not standard care, was also accompanied by deferred positive pressure ventilation for several minutes and deployment of a “pit crew” approach for more efficient placement of the mechanical CPR device.

Animal laboratory studies have also been performed evaluating this technique (also in concert with mechanical CPR and an impedance threshold device) with mixed outcomes but were not included in this review which focused on available clinical information.

Treatment Recommendations

We suggest against the routine use of head-up CPR during CPR (weak recommendation, very-low-certainty evidence).

We suggest that the usefulness of head-up CPR during CPR be assessed in clinical trials or research initiatives (weak recommendation, very-low-certainty evidence).

Justification and Evidence to Decision Framework Highlights

This topic was prioritized by the BLS Task Force based on increasing interest and debate surrounding head-up CPR within the resuscitation community. The BLS Task Force was aware of the growing body of animal research addressing head-up CPR,(2-7) and aware that this strategy is currently being used in some Emergency Medical Services Systems.

The limited observational evidence identified in this review suggest head-up CPR might have the potential to improve short-term outcome from cardiac arrest, but the certainty of evidence is very low with very high risk of bias. Head-up CPR was only assessed as a bundle with mechanical CPR with active decompression and the use of an impedance threshold device questioning the generalizability of the results to other systems. With a before-and-after design, the study is also at additional risk of being influenced by unrelated changes in practice with time which are not fully reported in particular, a change in ventilation strategy and potentially more efficient deployment of mechanical CPR that accompanied the intervention. Outcome measures were also limited to ROSC to hospital arrival, without any information on longer-term survival or functional outcomes.

Implementation of head-up CPR requires purchase of expensive equipment (mechanical CPR and the impedance threshold device), along with a substantial amount of education and training both in the use of this equipment and in the manner in which head-up CPR itself is deployed. Without a demonstrable improvement in longer-term outcomes, it is unlikely to be an acceptable strategy for key stakeholders. The Basic Life Support Task Force does not find the current evidence sufficient to recommend routine use of this strategy and encourages further research before its clinical deployment.

Knowledge Gaps

  • We did not identify any RCTs that evaluated the effect of head-up CPR
  • In the identified observational study, only short term/surrogate outcomes were evaluated, and future studies should document survival/neurologically intact survival to hospital discharge/30days.
  • Head-up CPR has only been evaluated as a bundle with mechanical CPR with active decompression and the use of an impedance threshold device.

Attachment: Et D_BLS-Head-up-CPR


1. Pepe PE, Scheppke KA, Antevy PM, Crowe RP, Millstone D, Coyle C, et al. Confirming the Clinical Safety and Feasibility of a Bundled Methodology to Improve Cardiopulmonary Resuscitation Involving a Head-Up/Torso-Up Chest Compression Technique. Critical care medicine. 2019;47(3):449-55.

2. Debaty G, Shin SD, Metzger A, Kim T, Ryu HH, Rees J, et al. Tilting for perfusion: head-up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest. Resuscitation. 2015;87:38-43.

3. Ryu HH, Moore JC, Yannopoulos D, Lick M, McKnite S, Shin SD, et al. The Effect of Head Up Cardiopulmonary Resuscitation on Cerebral and Systemic Hemodynamics. Resuscitation. 2016;102:29-34.

4. Kim T, Shin SD, Song KJ, Park YJ, Ryu HH, Debaty G, et al. The effect of resuscitation position on cerebral and coronary perfusion pressure during mechanical cardiopulmonary resuscitation in porcine cardiac arrest model. Resuscitation. 2017;113:101-7.

5. Moore JC, Salverda B, Rojas-Salvador C, Lick M, Debaty G, K GL. Controlled sequential elevation of the head and thorax combined with active compression decompression cardiopulmonary resuscitation and an impedance threshold device improves neurological survival in a porcine model of cardiac arrest. Resuscitation. 2021;158:220-7.

6. Rojas-Salvador C, Moore JC, Salverda B, Lick M, Debaty G, Lurie KG. Effect of controlled sequential elevation timing of the head and thorax during cardiopulmonary resuscitation on cerebral perfusion pressures in a porcine model of cardiac arrest. Resuscitation. 2020;149:162-9.

7. Park YJ, Hong KJ, Shin SD, Kim TY, Ro YS, Song KJ, et al. Worsened survival in the head-up tilt position cardiopulmonary resuscitation in a porcine cardiac arrest model. Clinical and experimental emergency medicine. 2019;6(3):250-6.



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