Confirming the Clinical Safety and Feasibility of a Bundled Methodology to Improve Cardiopulmonary Resuscitation Involving a Head-Up/Torso-Up Chest Compression Technique

Abstract

Objectives: Combined with devices that enhance venous return out of the brain and into the thorax, preclinical outcomes are improved significantly using a synergistic bundled approach involving mild elevation of the head and chest during cardiopulmonary resuscitation. The objective here was to confirm clinical safety/feasibility of this bundled approach including use of mechanical cardiopulmonary resuscitation provided at a head-up angle.

Design: Quarterly tracking of the frequency of successful resuscitation before, during, and after the clinical introduction of a bundled head-up/torso-up cardiopulmonary resuscitation strategy.

Setting: 9-1-1 response system for a culturally diverse, geographically expansive, populous jurisdiction.

Patients: All 2,322 consecutive out-of-hospital cardiac arrest cases (all presenting cardiac rhythms) were followed over 3.5 years (January 1, 2014, to June 30, 2017).

Interventions: In 2014, 9-1-1 crews used LUCAS (Physio-Control Corporation, Redmond, WA) mechanical cardiopulmonary resuscitation and impedance threshold devices for out-of-hospital cardiac arrest. After April 2015, they also 1) applied oxygen but deferred positive pressure ventilation several minutes, 2) solidified a pit-crew approach for rapid LUCAS placement, and 3) subsequently placed the patient in a reverse Trendelenburg position (~20°).

Measurements and main results: No problems were observed with head-up/torso-up positioning (n = 1,489), but resuscitation rates rose significantly during the transition period (April to June 2015) with an ensuing sustained doubling of those rates over the next 2 years (mean, 34.22%; range, 29.76-39.42%; n = 1,356 vs 17.87%; range, 14.81-20.13%, for 806 patients treated prior to the transition; p < 0.0001). Outcomes improved across all subgroups. Response intervals, clinical presentations and indications for attempting resuscitation remained unchanged. Resuscitation rates in 2015-2017 remained proportional to neurologically intact survival (~35-40%) wherever tracked.

Conclusions: The head-up/torso-up cardiopulmonary resuscitation bundle was feasible and associated with an immediate, steady rise in resuscitation rates during implementation followed by a sustained doubling of the number of out-of-hospital cardiac arrest patients being resuscitated. These findings make a compelling case that this bundled technique will improve out-of-hospital cardiac arrest outcomes significantly in other clinical evaluations.

Figure 1.

Prior experimental studies of porcine cardiac arrest (n = 28) following induced ventricular fibrillation demonstrating cerebral perfusion pressure measurements (in mm Hg) that were recorded during the first 20 min of arrest and basic cardiopulmonary resuscitation (CPR). Sequential comparisons in mean cerebral perfusion pressures with sem were made for four scenarios: 1) conventional CPR (C-CPR) performed in a supine (SUP) position (C-CPR SUP; n = 6); 2) conventional CPR with a head-up/shoulders/thorax tilted up (HUP) approach (C-CPR HUP; n = 6); 3) CPR performed with an active compression-decompression device (ACD) used in combination with an impedance threshold device (ITD) in a supine (SUP) position (ACD+ITD SUP; n = 8); and finally, 4) ACD+ITD CPR combined with a head-up/shoulders/thorax tilted up (HUP) approach (ACD+ITD HUP; n = 8). Results indicate a synergistic and sustained interaction when the ACD, ITD, and head-up strategies are combined*. *Adapted from our previous work: Ryu H et al (12).

Figure 2.

Procedure used by the emergency medical services agency to provide elevation of the head and torso during mechanical cardiopulmonary resuscitation using a LUCAS (Physio-Control Corporation, Redmond, WA) device attached to a scoop stretcher that is supported and angled upward (reverse Trendelenburg) with hard-edge case positioned toward the top end of the stretcher.

Figure 3.

Graphic display of emergency medical services resuscitation rates (successful resuscitation and delivery of a viable patient with spontaneous circulation to the hospital emergency department) expressed in terms of % resuscitated using quarterly reports beginning in January 1, 2014, and ending June 30, 2017. Each horizontal bar represents the resuscitation rate for each respective quarter. The transition period with introduction of the full resuscitation bundle including introduction of head-up mechanical cardiopulmonary resuscitation in Quarter (Q) 2 (April, May, June) 2015 is noted. Comparison of the mean rates of resuscitation before and after the transition are in indicated by the thick vertical lines flanked on each side with thinner vertical lines indicating the respective outer ranges of quarterly rates.

Figure 4.

The raw number of patients resuscitated by emergency medical services teams who were successfully delivered to the emergency department alive with sustained circulation for the calendar years 2014, 2015 (the year of transition with inclusion of head-up cardiopulmonary resuscitation), and 2016, respectively.