Heads-Up CPR (HUP-CPR) has emerged as an innovative approach to cardiopulmonary resuscitation (CPR), showcasing potential benefits in patient outcomes, particularly regarding neurological viability following cardiac arrests. The premise of heads-up positioning during CPR is based on the physiological advantages it offers, including improved cerebral perfusion and reduced intracranial pressure (ICP). Studies suggest that HUP-CPR, when combined with adjunctive resuscitation techniques, can enhance survival rates and neurological outcomes in both animal models and clinical settings (Moore et al., 2017; Moore, 2023; Pepe et al., 2019; Bachista et al., 2024)
Research indicates that elevating the head and thorax during CPR not only contributes to better hemodynamics but also bolsters critical perfusion to the brain. For instance, animals receiving active compression-decompression CPR in a heads-up position demonstrated improved cerebral perfusion pressure (CerPP) and earlier spontaneous gasps, indicative of preserved brain function post-arrest (Moore et al., 2017; (Pourzand et al., 2023; Arango et al., 2022; Pourzand et al., 2024).
These findings suggest that HUP-CPR could be superior to traditional CPR methods, particularly in long-duration resuscitations experienced during emergency responses. This advantage is poignant in high-rise building scenarios where response times are extended, thereby increasing the low-flow time before CPR initiation (Park et al., 2019; Damjanović et al., 2023).
However, outcomes associated with HUP-CPR are not universally established. A study involving porcine models indicated that prolonged head-up positioning could potentially worsen survival outcomes under certain circumstances, emphasizing the need for further investigation to delineate optimal positioning strategies during resuscitation (Park et al., 2019; Damjanović et al., 2023). While other investigations have reported improved neurological survival rates with automated heads-up positioning compared to conventional CPR techniques, discrepancies remain evident, highlighting the necessity for large-scale randomized controlled trials to confirm these benefits in human subjects (Moore, 2023; Pepe et al., 2019; Huang et al., 2021).
The critical role of adjunctive techniques, such as impedance threshold devices and active compression-decompression methods, further augments the efficacy of HUP-CPR. Combining these methods often results in enhanced cerebral blood flow and cardiac performance, driving better clinical outcomes when applied effectively (Pourzand et al., 2023; Arango et al., 2022; Moore, 2025). Observational studies support a time-sensitive association between HUP-CPR application and improved survival with favorable neurological status in out-of-hospital cardiac arrest scenarios (Bachista et al., 2024; Moore, 2025).
Moreover, the reduction in intracranial pressure observed during elevated positioning indicates a critical pathway through which HUP-CPR may mitigate secondary brain injuries that often accompany cardiac arrest events Levy et al., 2022). This aligns with broader goals of improving resuscitative techniques that focus not only on restoring circulation but also preserving neurological integrity (Chen et al., 2018; Levy et al., 2022). The implementation of head-up strategies in cardiac resuscitation protocols could potentially redefine critical care practices in both prehospital and hospital settings.
In conclusion, while preliminary animal studies and observational research suggest promising outcomes for heads-up CPR regarding cerebral perfusion and neurological recovery, further longitudinal studies are imperative to fully establish its clinical applicability and safety among diverse patient populations. Continued exploration into the interaction of CPR positioning with adjuncts will help refine cardiac arrest management strategies, ultimately aiming to enhance survivorship and functional recovery in victims of cardiac arrest.
References:
- Arango, S., Kshatriya, S., Metzger, A., Salverda, B., Lick, M., Moore, J., … & Lurie, K. (2022). Abstract 11244: active decompression during device assisted elevation of the head and thorax, an impedance threshold device, and active compression decompression cardiopulmonary resuscitation is needed for sustained hemodynamic benefit in a porcine model of prolonged cardiac arrest. Circulation, 146(Suppl_1).
https://doi.org/10.1161/circ.146.suppl_1.11244
- Bachista, K., Moore, J., Labarère, J., Crowe, R., Emanuelson, L., Lick, C., … & Pepe, P. (2024). Survival for nonshockable cardiac arrests treated with noninvasive circulatory adjuncts and head/thorax elevation*. Critical Care Medicine, 52(2), 170-181.
https://doi.org/10.1097/ccm.0000000000006055
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https://doi.org/10.4103/0366-6999.233946
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https://doi.org/10.3390/jcm12227054
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https://doi.org/10.1097/shk.0000000000001971
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https://doi.org/10.1097/mcc.0000000000001037
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https://doi.org/10.1161/circ.152.suppl_3.sun705
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https://doi.org/10.1097/ccm.0000000000003608
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https://doi.org/10.1161/circ.150.suppl_1.sa308