Head-up CPR: BLS Systematic Review

The current proposed head-up CPR recommendations are: 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). As one of the individuals involved with the discovery of head-up CPR, I am writing to respectively request that the ILCOR substantially modify the discussion and conclusions on this topic. A little history and commentary will hopefully provide some context for this request. When we first described the physiological benefits of head-up CPR in pig studies in 2015 we knew that elevation of the head and thorax would only be helpful if used in conjunction with CPR adjuncts, already shown and known to increase blood flow compared with conventional closed chest CPR. As such, a ‘bundle of care’ is needed for head-up CPR since blood needs to be pumped ‘up hill’. Conventional CPR just does not provide enough flow for this and, as a consequence, head-up CPR using conventional CPR is not of benefit and can be harmful. We described this imperative for the bundle more fully in an important letter to the editor in Resuscitation by Moore et al that should be referenced. (Moore J, Segal N, Debaty G, Lurie K. “The Do’s and Don’ts” of Head Up CPR: Lessons learned from the Animal Laboratory [Letter to the editor]. Resuscitation. 2018; 2018(129):e6-e7. doi.org/10.1016/j.resuscitation.2018.05.023.) The pig studies on head-up CPR are compelling and all are positive as long as certain now-known methods are followed. (Please note a complete reference list can be found at the end of this commentary – the references listed in the current proposed systematic review are incomplete). More specifically we have learn from pigs studies that one cannot elevate the head too fast or too high, one needs to use an impedance threshold device (ITD) for circulatory augmentation, and priming is needed to circulate blood before elevating the head and the heart. In more recent years we learned that a slow elevation sequence, elevating the head from about 10 cm in height to 24 cm in height and the heart from about 7 cm to 9 cm over 2 minutes, provides a significant increase in brain blood flow versus the flat position, when using either a LUCAS device or an automated active compression decompression (ACD) CPR. We also know the feet should not be lower than the abdomen or blood will eventually run downhill and that can be dangerous. These findings have been well-documented in pig studies from two different groups of investigators. The increase in blood flow to the heart and brain, the reduction in ICP, and the increase in neurologically-intact survival rates are striking when head-up CPR is performed correctly. For the first time this new approach helps drain venous blood from the brain, an inherent limitation of conventional flat CPR. The back up of venous blood in the brain during conventional CPR in the flat position and the constant bombarding of the brain with high venous pressures with each compression, reported in humans by Paridis et al in 1990 in humans, (JAMA 1990 Feb 23;263(8):1106-13) is a likely contributory factor to poor outcomes with conventional CPR. Head-up CPR attenuates these untoward effects of any method of CPR in the flat position. There are very limited published human data with this new approach. This fact is key to my request. Without peer-review human data it is premature to weigh in positively or negatively about head-up CPR. The proposed recommendations are negative in tone and will dissuade the use of head-up CPR for a long time. It would be far better for patients and progress in this CPR space for ILCOR to say something like: 'At the present time there are multiple positive animal studies but limited clinical data on a new approach to CPR called 'head up CPR'. Given the lack of clinical data, we cannot make any recommendations at this time regarding use of head-up CPR in patients in cardiac arrest. Further clinical data are needed." Importantly, the only published clinical article by Pepe et al used a jerry-rigged system to tilt the whole body upwards using a pelican case to prop up the head of the stretcher. While conceptually of value, it was not a study of head-up CPR by itself at all. The method was not standardized, there are no long-term endpoints, and multiple new interventions were introduced and performed simultaneously, including whole body head up tilt, preventing us from knowing which intervention resulted in more patients alive to hospital admission. Dr. Joanna Moore and others, including me, have started a Head-Up CPR Registry. She presented our first data at the AHA late-breaking session this past November and at NAEMSP this January. Time to start of a head-up CPR bundle of care is a critical determinant of outcome. We are learning how to best perform head-up CPR in patients. Similar to time to defibrillation, without rapid implementation of a head-up bundle, survival rates are similar to historical controls. A peer-reviewed manuscript is under preparation and should be submitted in 4-6 weeks. That will be the first published data on head-up CPR in patients where the only new intervention is device-assisted controlled sequential elevation of the head and thorax. The results are positive but still we still have a lot to learn. Rather than a treatment recommendation against the use of head-up CPR, based on little to no clinical data, it would be fairer and better for potential progress in this field to state what we know from pigs, which is very positive, emphasis the do’s and don’ts based upon lessons learned, and highlight the lack of published clinical studies and the need for such human data before ILCOR weighs in with a recommendation. That would be in-keeping with the manner in which ILCOR has traditionally assessed new approaches and it would not tilt the scales in the negative direction from the start with this new and promising approach. Thank you for your consideration of this request. Keith Lurie MD Head-Up CPR References Duhem H, Moore J, Rojas-Salvador C, Salverda B, Lick M, Pepe P, et al. Improving post-cardiac arrest cerebral perfusion pressure by elevating the head and thorax [Experimental Paper]. Resuscitation. 2021 February 2021;159:45-53. Moore JC, Salverda B, Rojas-Salvador C, Lick M, Debaty G, Lurie K. Controlled sequential elevation of the head and thorax combined with active compression decompression cardiopumonary resuscitation and an impedance threshold device improves neurological survival in a porcine model of cardiac arrest. Resuscitation. 2021 January 2021; 158:220-27. DOI:https://doi.org/10.1016/j.resuscitation.2020.09.030 Moore J, Salverda B, Lick M, Rojas-Salvador C, Segal N, Debaty G, Lurie K. Controlled progressive elevation rather than an optimal angle maximizes cerebral perfusion pressure during head up CPR in a swine model of cardiac arrest [Experimental Paper]. Resuscitation. 2020b; 150:23-28. Pepe P, Aufderheide T, Lamhaut L, Davis D, Lick C, Polderman K, et al. Rationale and Strategies for Development of an Optimal Bundle of Management for Cardiac Arrest. Critical Care Explorations. 2020. 2:e0214. Holley J, Moore J, Jacobs M, Rojas-Salvador C, Lick C, Salverda B, Lick M, Frascone RJ, Youngquist S, Lurie K. (2020). Supraglottic airway devices variably develop negative intrathoracic pressures: A prospective cross-over study of cardiopulmonary resuscitation in human cadavers. Resuscitation(2020), 32-38. https://doi.org/https://doi.org/10.1016/j.resuscitation.2019.12.022 Rojas-Salvador C, Moore J, Salverda B, Lick M, Debaty G, Lurie K. (2020). 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, EPub ahead of print. doi:10.1016/j.resuscitation.2019.12.011 Park Y, Hong K, Shin S, Kim T, Ro Y, Song K, Ryu H. (2019). Worsened survival in the head-up tilt position cardiopulmonary resuscitation in a porcine cardiac arrest model. Clnical and Experimental Emergency Medicine, 6(3), 250-256. https://doi.org/https://doi.org/10.15441/ceem.18.060 Pepe P, Scheppke K, Antevy P, Crowe R, Millstone D, C Moore J, Holley J, Segal N, Lick M. et al. Consistent head up cardiopulmonary resuscitation haemodynamics are observed across porcine and human cadaver translational models. Resuscitation. 2018; 132: 133-139. https://doi.org/10.1016/j.resuscitation.2018.04.009 Moore J, Segal N, Lick M, Dodd K, et al. Head and thorax elevation during active compression decompression cardiopulmonary resuscitation with an impedance threshold device improves cerebral perfusion in a swine model of prolonged cardiac arrest. Resuscitation. 2017;2017(121):195-200. doi: http://dx.doi.org/10.1016/j.resuscitation.2017.07.033. 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; 113:101-107. doi: https://doi.org/10.1016/j.resuscitation.2017.02.008. Ryu H, Moore J, 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. Debaty G, Shin S, 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(2015):38-43. Letters to the Editor Moore J, Segal N, Debaty G, Lurie K. “The Do’s and Don’ts” of Head Up CPR: Lessons learned from the Animal Laboratory [Letter to the editor]. Resuscitation. 2018; 2018(129):e6-e7. doi.org/10.1016/j.resuscitation.2018.05.023 Putzer G, Martini J, Helbok R, Mair P. Reply to “The Do’s and Don’ts” of Head Up CPR: Lessons learned from the Animal Laboratory [Letter to the Editor]. Resuscitation. 2018; 2018(129):e8. doi:10.1016/j.resuscitation.2018.06.006. Editorials Paxton J, O'Neil B. Is ‘heads up’ the way forward [Editorial]. Resuscitation. 2020;158:270-272. Gazmuri R and Dhliwayo N. From a toilet plunger to head-up CPR: Bundling systemic and regional venous return augmentation to improve the hemodynamic efficacy of chest compression [Editorial]. Resuscitation. 2020;2:Online Strobos, NC. Debunking another CPR myth: Lay the patient flat, or head up CPR? [Editorial]. Resuscitation. 2018;132:A1-A2. https://doi.org/10.1016/j.resuscitation.2018.07.010 Review Articles Elphinstone A, and Laws S. Does ‘heads-up’ cardiopulmonary resuscitation improve outcomes for patients in out-of-hospital cardiac arrest? A systematic review [Literature Review]. British Paramedic Journal. 2020;4(4):16-24 Lurie K, Nemergut E, Yannopoulos D, Sweeney M. The Physiology of Cardiopulmonary Resuscitation [Review Article]. Anesthesia & Analgesia. 2016;122(3):767-783.

As one of the researchers involved with the discovery of head-up CPR, I am writing to request that the ILCOR substantially modify its recommendation on the subject. As pointed out, most of the evidence available to date is experimental. The positive effects in preclinical settings were only observed with the use of a bundle of care including active compression decompression CPR (ACD), the use of an ITD and progressive elevation of the head and torso (HUP) [1-6]. I’m feeling that the current writing of your consensus on science and justification doesn’t reflect the need to use this bundle of care. For human clinical evidence, we are currently running the first pilot clinical study to assess the fully integrated system of ACD+ITD HUP CPR : NCT03996616. Taking in consideration the lack of clinical evidence to date on the bundle of care, with only one clinical study by Pepe et al [7] assessing multiple different interventions including an elevation of the stretcher head, I think any conclusion on clinical use of head-up CPR would be premature. The Pepe study, while offering interesting preliminary data, is very different than the bundle assessed in animal studies. Based on these comments, in my opinion with the current data available, it would be better to make no recommendation on the subject because the available evidence would make any estimate of effect speculative. [1] Moore JC, Salverda B, Rojas-Salvador C, Lick M, Debaty G, Lurie K. 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. [2] 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. [3] Moore JC, Salverda B, Lick M, Rojas-Salvador C, Segal N, Debaty G, et al. Controlled progressive elevation rather than an optimal angle maximizes cerebral perfusion pressure during head up CPR in a swine model of cardiac arrest. Resuscitation. 2020;150:23-8. [4] Moore JC, Segal N, Debaty G, Lurie KG. The "do's and don'ts" of head up CPR: Lessons learned from the animal laboratory. Resuscitation. 2018;129:e6-e7. [5] Moore JC, Holley J, Segal N, Lick MC, Labarere J, Frascone RJ, et al. Consistent head up cardiopulmonary resuscitation haemodynamics are observed across porcine and human cadaver translational models. Resuscitation. 2018;132:133-9. [6] Moore JC, Segal N, Lick MC, Dodd KW, Salverda BJ, Hinke MB, et al. Head and thorax elevation during active compression decompression cardiopulmonary resuscitation with an impedance threshold device improves cerebral perfusion in a swine model of prolonged cardiac arrest. Resuscitation. 2017;121:195-200. [7] 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. Crit Care Med. 2019;47:449-55.