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Review
. 2025 Jun 16:25:101007.
doi: 10.1016/j.resplu.2025.101007. eCollection 2025 Sep.

Effects of head-up CPR on survival and neurological outcomes: A systematic review

Tatsuya Norii  1   2 , George Lukas  3 , Aloka Samantaray  4 , Mio Yabuki  5 , Theresa M Olasveengen  6 , Janet E Bray  7   8 ; International Liaison Committee on Resuscitation ILCOR Basic Life Support Task Force
Affiliations
Review

Effects of head-up CPR on survival and neurological outcomes: A systematic review

Tatsuya Norii et al. Resusc Plus. .

Abstract

Background: The impact on survival and neurological outcomes of head-up cardiopulmonary resuscitation (CPR) remains unclear. This systematic review aimed to examine whether head-up CPR or head-up CPR bundle affects survival and neurological outcomes.

Methods: In this review registered in PROSPERO (CRD42024541714), we searched Medline, EMBASE, Scopus, Emcare and Cochrane library from inception to February 12, 2025. The inclusion criteria were studies: in adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest, comparing head-up CPR or head-up CPR bundle with standard or compression-only CPR in supine position, and randomized controlled trials (RCT) and observational studies. We excluded non-human studies and used Cochrane's Risk of Bias-2 and ROBINS-I tools for risk of bias assessment, and GRADE for outcome assessment. We conducted a narrative synthesis of the findings.

Results: We identified four observational studies with 10,099 participants and no RCTs. All outcomes were judged to be very-low certainty of evidence, subject to high-risk of bias. Two pre- and post-intervention studies showed no statistically significant difference in survival with a good neurological outcome. The other two studies, which analyzed overlapping cohorts comparing the head-up CPR bundle with conventional CPR, showed mixed results-one found no statistically significant difference in survival to hospital discharge with favorable neurological status, while the other, focusing on patients with nonshockable rhythms, found that the head-up CPR bundle was associated with increased survival with favorable neurological function.

Conclusions: The available evidence remains limited, highlighted by the absence of RCTs or observational studies with adequate comparisons.

Keywords: Cardiopulmonary resuscitation; Chest compression; Head-up CPR; Heart arrest; Resuscitation.

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Conflict of interest statement

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Some of the Task Force collaborators (G Debaty and L Morrison) have published manuscripts related to head-up CPR which are included in this review. However, none of the authors have any financial conflicts of interests and none of the authors have academic conflicts related to ongoing or planned trials. Authors with identified conflicts of interest as per the guidance of the ILCOR Conflict of Interest Committee were not involved in the decision to include/exclude those articles and did not perform the initial data extraction or bias assessment. Janet E Bray is an Editor and Theresa M Olasveengen is an Editorial Board Member for Resuscitation Plus. Janet E Bray and Theresa M Olasveengen are Editorial Board Members for Resuscitation.

Figures

Fig. 1
Fig. 1
PRISMA diagram for study selection.
See this image and copyright information in PMC

References

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