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Patient Care

Heads-Up CPR: Can Elevating the Patient’s Head Improve Outcomes?


The next important innovation in CPR could be right around the corner.

Following some promising findings in lab research and bolstered by a strong theoretical case for its efficacy, several EMS systems in South Florida have begun performing what’s known as heads-up CPR. It entails elevating the patient’s head during resuscitation to allow gravity to help improve blood flow in and out of the brain.

“There’s such a long history of poor survival for adult cardiac arrest despite all the things we’ve done,” says Ken Scheppke, MD, medical director for Palm Beach County Fire Rescue, one of the agencies trying the innovation, “that when something comes along like this—it’s simple, but there’s a good, clear-cut sense that it should help physiologically—I think we should keep trying new ideas to improve care for that segment of the population.”

Lab work is ongoing and clinical trials forthcoming, and this implementation—by a half-dozen agencies in Palm Beach County and two in Broward—lays important groundwork by demonstrating safety and feasibility. It may also be hinting at benefit, as it’s helped boost Palm Beach County Fire Rescue’s all-rhythm ROSC rate from 16% to 23%.

Elevation of the head is just one piece of the plan, though. Also involved are mechanical chest compressions, an ITD and, in Palm Beach County, a scoop stretcher. PBCFR’s method, largely conceived by field personnel, calls for placing the patient on a LUCAS device and scoop, then placing a Pelican case on the stretcher before the patient. Personnel then raise the stretcher head and run the shoulder and waist straps through the scoop handles.

Top EMS docs heard about the idea at February’s Gathering of Eagles conference, where renowned emergency physician Paul Pepe, MD, shared the results of research led by French physician Guillaume Debaty. Using a LUCAS device and ITD, Debaty and company measured organ blood flow in arresting pigs supine, with a 30-degree head-up tilt (HUT) and with a 30-degree head-down tilt (HDT). The HUT was associated with better coronary perfusion pressure, better cerebral perfusion pressure and better brain blood flow.1

Why does it work? Basically, standard supine chest compressions increase arterial and venous pressures simultaneously, reducing the possibility of a cerebral perfusion gradient. Conversely, elevating the head uses gravity to help drain the brain, and the LUCAS (some systems are using AutoPulses) and ITD help enhance flow further.

“We’re still learning about this concept and thinking through the process, but it’ll be pretty interesting to see where it all settles,” says Peter Antevy, MD, associate medical director for PBCFR and medical director for two Broward County services also now using the head-up approach. “We now have almost all of Palm Beach County and small pockets of Broward County doing it, which will give us data back, like a small field trial. If we can get some good data out even before a randomized trial, that may speed up the whole process.”

“What these guys are doing in South Florida is developing excellent groundwork for a controlled clinical trial,” says Pepe. “They’re showing that it’s possible and can be done, and without safety issues. We’ll do the controlled trials later, but they’re doing invaluable work right now by advancing the concept in terms of seeing if it’s feasible.”

For more on heads-up CPR, see the special August issue of EMS World Magazine.


1. Debaty G, Shin SD, Metzger A, Kim T, Ryu HH, Rees J, McKnite S, Matsuura T, Lick M, Yannopoulos D, Lurie K. Tilting for perfusion: head-up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest. Resuscitation, 2015 Feb; 87: 38–43. 

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