Resuscitation More Likely With Faster Time to Head-Up CPR

Marlene Busko

November 25, 2020

A preliminary study of adults who experienced out-of-hospital cardiac arrest (OHCA) and received cardiopulmonary resuscitation (CPR) that included the use of a device to elevate the head and thorax not surprisingly showed again that speed matters.

Results showed that the probability of return of spontaneous circulation (ROSC) decreased as the time from the 911 call — or from the arrival of emergency medical service (EMS) personnel — until the start of the use of the EleGARD Patient Positioning System (Advanced CPR Solutions) increased.

The EleGARDTM Patient Positioning System.

Johanna C. Moore, MD, presented the study in a late-breaking resuscitation science session at the virtual American Heart Association (AHA) Scientific Sessions 2020.

"I think this relationship is important to know about as we go forward with studying and recommending this technology, ie, [the device] is more effective the more quickly it is placed," Moore told theheart.org | Medscape Cardiology in an email.

The findings are consistent with preclinical studies and are "consistent with other principles in resuscitation where things like the time to start of CPR and first shock are also more effective the more quickly they are performed," added Moore, who is research director in the Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota.

The protocol involved a "bundled" approach. In addition to using the head-up/torso-up positioning device, the EMS responders performed one or more of three types of CPR — manual CPR, active compression decompression CPR (using the ResQPump, Zoll), or automated CPR (most commonly using the LUCAS mechanical chest compression device, Stryker) — while using an impedance threshold device.

"At this point, very few EMS agencies use any form of head and thorax elevation — primarily the agencies involved in this research study," noted Benjamin S. Abella, MD, University of Pennsylvania, Philadelphia, Pennsylvania, who was not involved in the study.

"The investigation suggests that head elevation, in combination with automated CPR, may improve hemodynamics and cardiac arrest outcomes. However, the challenge in interpreting studies like this is that the authors implemented several things as a 'package,' and it's hard to know which component is most important," he told the heart.org | Medscape Cardiology.

"In my opinion," said Abella, who was co-chair of the Resuscitation Science Symposium during the AHA meeting, "a randomized trial is needed before broad implementation should be considered.”

Moore conceded that there are not enough data at this point to make definitive recommendations. Moreover, head-up CPR needs to be performed by experienced EMS responders.

"The systems where this technology is currently being used are high-functioning systems that see cardiac arrest routinely," she stressed.

Time to Head-Up CPR Varied Widely

"The EleGARD System is an FDA-cleared and CE-marked patient positioning device and cardiopulmonary board" that is "intended to assist in elevating the head and the thorax of a patient from a supine position into a multi-level elevated position," according to the company website.

"An important part of the instruction for device use," Moore added, "is that the patient have CPR (any or combination of CPR methods described above) performed at the lowest level of the EleGARD [not quite flat] to 'prime' the cardiocerebral circuit for 2 minutes."

"Then the head and thorax are gradually elevated over an additional 2 minutes to full elevation," she continued. This is done in a slow progressive rise of 6 cm/min over 2 minutes to a head height of 22 cm and a thorax height of 8 cm.

Patient with mechanical CPR bundle.

In the current study, the researchers hypothesized that a faster time to elevation of the head/thorax during CPR would improve ROSC.

Using registry data, they identified 198 adults aged 18 and older who experienced OHCA during the period March 2019 to July 2020 and received head-up CPR from EMS personnel at five sites in Florida, Minnesota, Arkansas, Tennessee, and Ohio. The mean age of the patients was 67 years (interquartile range, 54 – 79), and 62% were men.

Sixty patients (30%) had ROSC. For most patients, the initial presenting rhythm was asystole (63%). For the other patients, it was pulseless electrical activity (21%) or ventricular fibrillation/tachycardia (16%).

Of the patients with ventricular fibrillation/tachycardia, 78% had experienced at least one failed shock prior to head-up CPR.

The median times from the 911 call until head-up CPR were 6, 10, 16, 14, and 19 minutes for sites with 5, 9, 78, 80, and 40 patients with cardiac arrest, respectively (P = .0001).

The median times from EMS personnel arrival until head-up CPR also varied widely for these sites: 2.7, 2.5, 7, 6, and 14 minutes, respectively (both P = .0001).

For all initial presenting rhythms, the probability of ROSC decreased by 6.7% for each minute delay in time from the 911 call to head-up CPR (P = .01) and by 2.5% for each minute delay from EMS arrival until head-up CPR (P = .14).

For patients with initial ventricular fibrillation/tachycardia, the probability of return of spontaneous circulation decreased by 6.7% for each minute delay in time from 911 call to head-up CPR (P = .04) and by 7.6% for each minute delay from EMS arrival to head-up CPR (P = .03).

Moore is an unpaid member of the scientific advisory board for Advanced CPR solutions. Abella has received honoraria from NeuroproteXeon, Becton Dickinson, and Physio-Control and research grants from Medtronic, PCORI, Physio-Control, Stryker, and TerSera.

American Heart Association (AHA) Scientific Sessions 2020: RESS 2020 Late Breaking Science 103. Presented November 14, 2020.

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