Resident Eagle: Head-Up CPR and Other Highlights from Florida

Resident Eagle is a monthly column profiling the work of top EMS physicians and medical directors from the Metropolitan EMS Medical Directors Global Alliance (the "Eagles"), who represent America’s largest and key international cities. For information on the Gathering of Eagles 2022, see useagles.org.

Packing its customary 70–80 condensed educational talks from EMS physicians into two brain-busting days, the Gathering of Eagles was back in person in June, joined with the popular First There First Care Conference at a glitzy new home, the Seminole Hard Rock Casino and Hotel in Hollywood, Fla. 

The Eagles’ familiar format still covered new research, best practices, and the latest clinical developments, salted with expert perspective from the EMS medical directors of the largest American cities and selected guest clinical heavyweights. Here are some highlights. 

Head Elevation and a Care Bundle

EMS World has reported previously on the promise of head-up CPR, in which the head is elevated during compressions to let gravity help “drain the brain,” reduce intracranial pressure, and improve cerebral perfusion. That’s done as one component of a bundle of care that also typically involves measures like automated compressions, active compression-decompression (ACD) CPR, and use of an impedance threshold device (ITD). Recent research has focused on details like the optimal point in the resuscitation sequence and rate at which to elevate the head and torso. 

The idea, says Ken Scheppke, MD, medical director for Florida’s Palm Beach County, where they embraced an early version of head elevation more than five years ago, is that “to add more water to a [full] bucket, you have to tilt some out.” In other words, during CPR, the brain is bombarded with blood from both sides with each push on the chest, including from the venous side—pushing more blood into a bucket that’s full. Head and torso elevation lets some of that blood flow out during compression recoil. The ACD and ITD add pull on the venous side, and in concert it all reduces resistance to forward flow and primes the brain for the next push.

Research to date suggests much promise. Data has shown CPR with ACD, ITD, and controlled sequence head/thorax elevation (CSE) can produce cerebral perfusion pressures greater than 80% of baseline after seven minutes of CPR, and in a study published this year, CPR with CSE, ITD, and ACD produced ROSC in 100% of pigs in VF, leaving 75% with CPC scores of 1 or 2. 

Palm Beach County, after refining its approach over the last half-decade, has seen its survival to admission top 40% even among patients with PEA/asystole. “What we saw was remarkable,” said Scheppke. 

Like many cardiac arrest interventions, time seems to matter with elevating the head: A cumulative study of survival to discharge vs. a propensity-matched standard CPR cohort showed diminishing results the longer it took to elevate, with best results—a survival to discharge approaching 35%—achieved when it took less than seven minutes. By the time it took 20, it provided little benefit over conventional CPR. A similar curve occurred with favorable neurological outcomes. 

That real “a-ha!” moment of recent research, Scheppke said, was realizing the order of interventions is as important as what those interventions are. Reorienting from ABC to CAB in cardiac arrest, he said, has yielded big improvements in ROSC. With head elevation, a 2020 study found no clear angle that’s always best, but controlled progressive elevation appeared more beneficial than an absolute angle or height.

Some dos and don’ts of head-up CPR, as determined from recent research and described by one of its leading investigators, Hennepin Healthcare’s Johanna Moore, MD:

• Do use circulatory adjuncts (ITD, automated CPR, ACD);
• Do “prime” the cardiocerebral circuit with 120 seconds of CPR before elevating; 
• Do elevate the head and chest/shoulders only during CPR;
• Don’t elevate the head for standard CPR alone; 
• Don’t raise the head immediately; 
• Don’t avoid elevating the body over prolonged effort;
• Don’t elevate too quickly or to an absolute height/angle—sequence matters.

Take Heart America wants to help spread adoption of the head-up bundle, and speakers noted it can be a BLS effort. San Antonio, for one, is pushing it out to firefighters. 

The Eagles’ cardiac arrest content segued neatly into a proposal for resuscitation centers, where the best practices begun by EMS can continue in the hospital setting. These would have defined criteria and capabilities much like trauma centers. There are lots of pieces to get right, and they work synergistically, noted Eagles creator and program director Paul Pepe, MD. 

Slovis’ Top Five

Nashville Fire medical director Corey Slovis, MD, delivered his traditional selection of the top five research papers of the year and their takeaways:

• Be careful with epi in cardiac arrest—it may help increase ROSC and survival but is also linked with neurologic devastation. The search for the best balance continues, but in the interim don’t give too many doses. 
• Monitor your agency’s CPR performance. Optimal targets now appear to be 107 compressions per minute at a depth of 4.7 cm. 
• If initial shocks fail, double sequential defibrillation seems to work better with anterior-posterior pad placement than anterolateral. 
• In pediatric seizures, patients who received 0.1 mg/kg of Versed required redosing more often when they got it intranasally than intravenously or intramuscularly—but starting IVs in seizing patients remains unadvisable. Try 0.2 mg/kg IN instead. 
• Give epi as soon as anaphylaxis is diagnosed, regardless of severity, and repeat it sooner rather than later. 

Other Pearls

An update on the Twin Cities’ prehospital ECMO initiative reported that nearly a third of its patients survived to hospital discharge with cerebral performance scores of 1–2, and that ECMO now must be regarded as a key part of a high-performing system of cardiac care. 

Ft. Worth’s Veer Vithalani, MD, broached the largely unexplored topic of mechanical compression devices “walking,” or working themselves out of position, while on patients. If a device tilts, slides, or rotates, you’ll see a consistent rate of compressions but declining depth. Ensure use of all stabilizing straps and consider marking your target spot with a Sharpie to easily visualize any movement. 

Even experienced providers can have difficulty maintaining parameters in manual ventilation. Joe Holley, MD, medical director for Memphis, Shelby County, and the state of Tennessee, shared the results of a trial that used the Sotair flow-limiting device to guide a range of providers and found extended manual ventilation could be feasible in a pinch with such assistance. 

Anchorage CMO Michael Levy, MD, argued that much of what we think is refractory ventricular fibrillation may actually be recurrent instead, and that a slight pause after a number of fruitless shocks may be warranted. 

An update on COVID from epidemiologist Michael Osterholm, PhD, observed we’ve entered the “age of the variants,” and the current delta variant is more severe and transmissible than earlier mutations. Many docs see a wave of that coming, and with more than 100 U.S. counties still having fewer than 20% given first doses of any COVID vaccine, “we still have a long ways to go.” 

Osterholm received the Eagles’ 2020 Paul Pepe Award for outstanding national contributions to EMS, and ESO research scientist Remle Crowe, PhD, won it for 2021. Scheppke claimed the 2020 Slovis Award for top EMS educator, while the University of Maryland’s Amal Mattu, MD, received it for 2021. 

John Erich is the senior editor of EMS World.