A new concept that is supposed to change the way EMS performs CPR in tight spaces is in the works from Florida. In fact, our Asians friends across the ocean found that head-up CPR on tight elevators may have been effective by allowing cerebral blood flow which prompted the idea of having it done and researched in the United States, with its EMS system. However, manual CPR is cumbersome because of the human factor of getting tired and maintaining a regular rate and rhythm, especially in a head up position. In this case, where a victim of cardiac arrest cannot be placed in a supine position, head-up CPR proves to be the only opportunity for the victim to survive.
Historically, CPR has been done in a supine position where the patient is placed on a hard surface. The technique has not changed as of this date, and with proper rate, rhythm, and with no interruptions, some patients survive to go home and live a normal life. In other situations, patients in cardiac arrest are found in awkward locations where the only thing to do is to work them in the position they were found but to move them means extended absence from chest compressions. This extended absence is not good and is not worthy of moving them until pronouncement or ROSC has been restored.
Paramedics have been frustrated for years because of the inability to resuscitate a victim in tight spaces. One would think that 21st century buildings would have improvements or upgrades that would allow plenty of space for the extrication of a cardiac arrest victim. However, some buildings and elderly care facilities across the country have not met those changes. Therefore, a compression device seems to be the best choice in those situations.
The Lucas device and its relatives are sufficient for those tight spaces, but the instructions for some agencies lack the procedure for head-up CPR. Let us not forget that head-up CPR is still in the research mode, and if it is found to be consistently having a greater than 95 percent success rate, its implementation will no doubt be instituted in training facilities and used by prehospital personnel on a regular basis. However, don’t expect to see it nationwide in the near future because, with research, time is the Achilles heel. In authenticity, greater than 50 percent should prove to be sufficient.
In some instances, up right CPR may be a 30-degree elevation of the head or full fowlers. Should cerebral performance improve, the chances of survival are also improved. Nonetheless, the down time and extensive or lack of a prolonged cardiac condition may bring different results. EMS should be aware that head-up CPR with ROSC does not mean that the patient is placed in a supine position. I have found that some patients who have ROSC wake up, and the first thing they want to do is sit up. Thus, attention should be given to the needs of the victim, especially if there is a congestive heart failure issue.
In my tenure of active emergency service and transport, I have found that when patients recover from cardiac arrest and are intubated, my fellow coworkers keep them laying in a supine position. This is even when the patient is trying to sit up and breath in a comfortable position. It is not unheard of to sit the patient up and ventilate or assist ventilations.
For the head-up CPR, the patient can benefit from doing something, rather than doing nothing. If one would visualize paramedics in New York or Chicago who respond to a high rise building for a victim in cardiac arrest, the best chance for the victim is to do head-up CPR. Well, in the first place, the paramedics may not transport the patient if ROSC is not achieved. However, for those who achieve ROSC, the patient is transported and placed on a tight elevator. While on the way down, the patient goes into cardiac arrest. The defibrillator is used even when the patient is in an awkward position, such as sitting up. In this situation, the defibrillator and chest compressions are essential.
Although head-up CPR is a skill that is in the research mode, it should be used presently because of the tight spaces. I am an advocate of proper CPR, even if it means doing it untraditionally. Hopefully, the head-up CPR position will become a tradition and widely accepted not only in the United States and China but around the world.