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CPR Alternatives: Revamping an Old Practice.... maybe


It has been well established in the literature that basic life support (BLS) measures really go a long way with overall patient survival -- especially when the interventions are started early. The chain of survival is paramount. This includes early activation of the EMS system, maximizing the time that the hands are on the chest, and early defibrillation. Medicine is no stranger to novel approaches and procedure enhancements as we are always looking to improve to sustain the lives of the patients we serve. To save a life is rewarding - but if the patient has neuro intact survival- that is the ultimate success story.

Many minds across the industry have over the past decade tried to leverage gravity to help blood flow both in and out of the brain. The argument is that when supine cerebral congestion becomes a problem and while you may get ROSC, you do so at the expense of the brain. Theoretically, it makes sense given that Cerebral Perfusion Pressure (CPP)= Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP). Elevating the patient reduces their ICP, so that should in turn, increase their CPP. Does this approach attain better organ perfusion than traditional methods alone??

Some forward-thinking medical directors have implemented this at their respective agencies.... but be cautious. As of late, the topic has once again gotten a lot of national attention. The overall consensus today is that we simply need more human related data. Proving optimization outside of animals is greatly limited. Due to this fact, it is way too early to consider this as the new standard of care.

Lateral Uterine Displacement in Pregnancy

This blog should also serve as a reminder that CPR in pregnancy may also have some physiological related caveats to be aware of on the streets. Cardiac arrest in pregnancy is one of the most challenging clinical scenarios. Although most features of resuscitating a pregnant woman are similar to standard adult resuscitation, several aspects and considerations are uniquely different. The most obvious difference is that there are 2 patients, the mother and the fetus. Fetal development and maternal maintenance of pregnancy require multiorgan physiological adaptations that are pertinent to the team responding to cardiopulmonary arrest during pregnancy.

Beyond 20 weeks' gestation, for example, chest compressions (a maternal intervention) will likely not be effective without left lateral uterine displacement (an obstetric intervention) - see center image below - because the pressure of the uterus limits the ability of compressions to circulate blood. Left lateral uterine displacement removes aortocaval compression which then improves the success of other resuscitative treatments. As mom approaches her 3rd trimester, aortocaval compression is clinically significant.... this intervention corrects for that.

Don't let this post discourage you from being a disruptive thinker. To get better we must continue to think outside of the box, we should just be rigorous in our approach and make interventions "the standard" - ONLY - once they meet the standard, that is free from bias and not made on animal or observational evidence alone.

Continue to keep your eye closely on this topic as more research will certainly be done over the next decade. Heads-Up CPR may indeed undergo widespread adoption at a later time. I also reinforce that one thing remains the same. CPR and defibrillation are still one of the few interventions that are scientifically proven to be game changer. -- Do those two things early, do those things well. Monitor your compression fraction, don't be overzealous with the BVM and keep training your communities. Prioritizing these will undoubtedly have a positive effect on mortality and outcomes.... there's no bias in that statement.

December 4, 2023

Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP

Pass with PASS, LLC.

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