Head’s Up!

When doing CPR it’s important for us to keep our head in the game. It’s a stressful time as we are trying to resurrect a recently dead person. The emotions can fill us; the desire to fight off the Grim Reaper and remember how to translate a class taught on a mannequin into real life. It’s easy for us to become overwhelmed and lose our head. But we also must consider the patient’s head as well.

When we are doing compressions we are only providing a small amount of blood movement to the heart, central organs and brain. I’ve covered in previous articles some advances in care being provided to improve our patient’s chance of resurrection. These have had great results to the return of a pulse, but didn’t always translate out to the patient’s neurological recovery. How many of us want our body to survive if our brain is severely damaged?

Scott M., a regular reader alerted me to a new study being conducted in Broward and parts of Palm Beach counties in Florida. After extensive studies with pigs in horizontal, Heads Down and Heads Up compressions they have found a significant reduction in Intracranial Pressure and an even more dramatic increase in Intracranial circulation with heads up compressions; the more blood going to your brain, the better its chance of maintaining neurological function.

Now, to be fair there are more variables added to this study rather than studying one at a time. The patient is placed on a scoop stretcher and a LUCAS machine (Or Autopulse) is applied to provide Positive Compression and Positive Decompression CPR automatically. They have also added an impedance threshold device (ITD) to an advanced airway to allow air to be expelled from the chest on compression, but prevented ambient air from returning to the lungs. This increases the vacuum in the thoracic cavity and returns better flow to the venous system, effectively increasing the pulling of the blood through the system. Because so many variables have been added simultaneously it will be difficult to determine exactly which is causing the greatest benefit. Both the LUCAS devices and the ITD have their own promising studies behind the products, but have not become the standard of care throughout the country.

But let’s consider the heads up portion only. When we compress we send pressure waves through the arteries of blood flow. We simultaneously send a pressure wave through the venous system as well causing the two to “crash into” each other and stop all blood flow. We’ve also known for years that vascular resistance really does not allow for an arterial flow during the compression portion of the cycle. Similar to blowing through a straw, too much pressure doesn’t change the output, but sucking can move a lot more fluid; It is the chest recoil that essentially pulls the blood through the system. The hypothesis of this study is that gravity will provide additional benefits and thus greater neurological outcomes.

Throughout the years we’ve tried many different ways to combat sudden cardiac death; In 1740 Mouth-to-mouth was recommended for the first time for drowning victims. In 1903 the first successful resuscitation with external chest compressions was recorded. In 1960 CPR was officially developed involving compressions and ventilations and was trained to physicians.  In the 1990s, public access defibrillators became available. Today these advances seem commonplace, but there have been very many years with very many skeptics that stood in the way of the system that we have today. Experimentation like this study will, whether it’s found useful or not, advance our care and help us resurrect more patients. It is this drive to move forward and make things better that moved us away from bloodletting many years ago. We must continue to learn new practices and be part of the research to advance the care for patients.

At least semi-annually we refresh our CPR skills and are taught how to position our body, hold our arms, push hard, but when put into real life we find that far too much time is spent off of the chest. Compressions with full chest recoil are the highest priority if we expect to resurrect the patient. Please watch this video by the Seattle EMS services designed to show how to properly run a cardiac arrest case.

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