From a toilet plunger to head-up CPR: Bundling systemic and regional venous return augmentation to improve the hemodynamic efficacy of chest compression

Survival for Nonshockable Cardiac Arrests Treated With Noninvasive Circulatory Adjuncts and Head/Thorax Elevation*

“…This study provides strong evidence that, compared with traditional closed-chest manual CPR performed in the supine/horizontal plane, OHCA patients with NS presentations can now have far higher likelihoods of SURV when treated by first-in responders who can amplify the lifesaving effects of C-CPR with rapid deployment of AHUP-CPR. These results confirm recent investigational breakthroughs in understanding the pivotal, synergistic role that gradual head/thorax elevation can play when combined with ITD/ACD-CPR (15, 17–23, 30–33).…”

“…Although the clear majority of NS-OHCA are unwitnessed events and often have lengthier response intervals, poor outcomes after NS-OHCA are also due to physiologic limitations of traditional CPR. Even for shockable cases, conventional CPR (C-CPR), performed early and appropriately, only provides ~20% of normal cerebral perfusion pressure (15)(16)(17)(18)(19)(20)(21). Chest compressions produce forward-flowing (arterial) pressure waves, but they also generate substantial retrograde venous pressure waves resulting in pulsatile increases in intracranial pressure with each compression, thus impairing trans-cerebral arterial flow (15)(16)(17)(18)(19)(20)(21).…”

“…Even for shockable cases, conventional CPR (C-CPR), performed early and appropriately, only provides ~20% of normal cerebral perfusion pressure (15)(16)(17)(18)(19)(20)(21). Chest compressions produce forward-flowing (arterial) pressure waves, but they also generate substantial retrograde venous pressure waves resulting in pulsatile increases in intracranial pressure with each compression, thus impairing trans-cerebral arterial flow (15)(16)(17)(18)(19)(20)(21). Coupled with limited refilling of cardiac chambers, C-CPR becomes progressively ineffective over time, especially with prolonged untreated cardiac arrest intervals (15,16).…”

“…Recent laboratory and clinical investigations have demonstrated new mechanisms to mitigate some of these inherent limitations of C-CPR. Noninvasive adjuncts, including the impedance threshold device (ITD) or use of suction cup-based active-compressiondecompression (ACD), have improved intrathoracic pressure regulation during CPR, both individually and particularly in combination (17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28). Leveraging these different, yet complementary, mechanisms of action, ITD/ACD-CPR lowers intracranial pressure, augments cardiac preload, and improves coronary and cerebral perfusion pressures (15,17,19).…”