This annotated bibliography provides an overview of current publications related to the
ElevatedCPR® Method, often reported in the literature as ‘Elevated CPR,’ ‘Head Up CPR’ or ‘gravity
assisted CPR.’ It includes current research, commentary, and publications important to
understanding the potential benefit and physiology of the ElevatedCPR Method, other key topics
surrounding the ElevatedCPR Method, as well as publications reporting no potential benefit from
Head Up Position CPR.
The following abbreviations are used throughout this document:
HUP: Head Up Position, SUP: Supine Position, CPR: Cardiopulmonary Resuscitation, NP-CPR:
Neuroprotective CPR, C-CPR: Conventional CPR, ACD: Active Compression Decompression, ITD:
Impedance Threshold Device, CerPP: Cerebral Perfusion Pressure, CorPP: Coronary Perfusion
Pressure, ICP: Intracranial Pressure, VF: Ventricular Fibrillation, MAP: mean arterial pressure, BLS:
Basic Life Support, DACSE: Device Assisted Controlled Sequential Elevation, ROSC: Return of
I. Physiology and Potential Benefits of the Head and Thorax Elevation
1. Pepe PE, Moore J, Labarere J, Lick CJ, Scheppke KA, Antevy PM, et al. Clinical confirmation
of profound improvements in neuro-intact survival using the head-up bundle. Critical Care
Medicine. 2022; 50:1 Supplement. Abstract #2. doi:
These authors analyzed data from a prospective national registry of pre-hospital
providers using Neuroprotective (NP) CPR, the triad of the EleGARDTM Patient
Positioning System, an impedance threshold device (ITD) and manual active
compression decompression (ACD) CPR and/or a suction cup-based automated CPR
compression device. Using propensity match scoring and multivariate regression
analyses, the study compared 227 patients treated with NP-CPR from 6 prehospital
systems that consistently implemented this strategy with more than 5000 control
subjects treated with conventional (C) CPR from three large, published NIH-funded
North American CPR clinical trials. Multivariate and propensity score analyses
accounted for imbalances in characteristics (age; sex; bystander-witnessed; bystander
CPR; shockable rhythm; call from time from 9-1-1 to C-CPR or NP-CPR by EMS providers
(T911-CPR). For the propensity score analyses, each NP-CPR patient was matched with
4 C-CPR patients (n=908).
Regardless neurologically-intact survival versus CCPR
controls. Even when compared with high-performance/highly-monitored EMS
systems and stratified by T911-CPR, neurologically favorable survival differences with
the NP-CPR became increasingly more significant than C-CPR with shorter T911-CPR:
neurologically-intact survival was nearly 3-fold higher with T911-CPR < 13 mins [OR 2.68;
95% CI=1.17-6.13] and nearly 5-fold higher [OR 4.74; 95% CI=1.40-16.01] if < 8 mins). The
study concludes that NP-CPR was associated with markedly improved odds of
neurologically favorable OHCA survival versus C-CPR even when comparing wellmatched
controls with closely-monitored CPR performance. Moreover, shorter times to
initiation of NP-CPR further augmented the odds of neuro-intact survival.
This abstract was ranked #2 of 1368 papers received by the Society for Critical Care
Medicine for the 51st Annual Conference and was awarded 2022 Star Research
Achievement Award in the Cardiovascular category.
2. Moore J, Labarere J, Lick C, Duval S, Holley J, Scheppke K, et al. A head up bundle of
care bundle improves the likelihood of survival to hospital discharge after out of
hospital cardiac arrest. American Heart Association Resuscitation Science
Symposium; Virtual. Nov 12, 2021.
This abstract provides the first human outcome data using a head up CPR
bundle of care that includes the EleGARD Patient Positioning System, manual
ACD CPR and/or automated suction-cup based CPR, and an ITD. This triad of
treatments is now called neuroprotective (NP) CPR. Investigators analyzed
outcome data from IRB approved registry of patients treated after out-ofhospital
cardiac arrest (OHCA). Using a prospective observational study design,
patients treated with NP-CPR from sites that consistently used this approach
and tracked 9-1-1 call to EleGARD placement data (n=227) were compared with
control patients (n=5352) from 3 large, randomized, NIH-funded CPR trials from
high-performing US EMS systems. Using multivariate regression analyses and
propensity score matching, NP-CPR treatment was associated with a
significantly higher likelihood of survival to hospital discharge and
neurologically favorable survival compared with conventional C-CPR controls.
After propensity-score matching, the odds ratio (OR) of survival to hospital
discharge for NP-CPR relative to C-CPR were 4.02 (95% confidence interval [CI],
1.68 to 9.62) and 2.01 (95% CI, 1.07 to 3.79) when NP-CPR was initiated within 10
and 15 minutes after the emergency call for help, respectively. The
corresponding ORs of favorable neurological survival were 3.43 (95% CI, 1.21 to
9.71) and 1.91 (95% CI, 0.91 to 4.03), respectively. Thus, compared with matched
C-CPR controls rapid NP-CPR application was associated with a significantly
higher probability of survival to hospital discharge after OHCA.
***Note: this abstract has been submitted for peer review publication.
3. Moore J, Duval S, Lick C, Holley J, Scheppke K, Slaverda B, et al. Faster time to automated
elevation of the head and thorax during cardiopulmonary resuscitation increases the
probability of return of spontaneous circulation. Resuscitation. 2021. EPub ahead of print.
The authors used an IRB-approved, prospective, observational CPR registry to track
use and clinical outcomes from a bundle of care approach to SCA that included use of
the EleGARD Patient Positioning System. There were 227 cases from 6 geographically
diverse sites that included time from 911 to placement of the EleGARD (automatic HUP
device or AHUP device) as surrogate for full SCA bundle deployment. Statistical
analyses were performed on the data with Return of Spontaneous Circulation (ROSC)
as the primary endpoint. The analysis found a ROSC rate of 34% for all presenting
rhythms and 47% for shockable rhythms. The faster time to EleGARD deployment, the
higher the probability of ROSC. ROSC decreased 5.6% for every minute delay for all
rhythms and 9% for shockable rhythms.
This new finding has important implications for deployment of EleGARD as part of a
bundle of care. Strategies to decrease time from 911-EleGARD placement should be
considered when implementing care. Agencies that deployed the EleGARD bundle on
first response vehicles had the shortest implementation times and higher ROSC rate.
4. Moore J, Pepe P, Bachista K, Holley J, Kewitsch W, Lurie K, et al. Carry less, do more:
Properly implementing a basic life support approach to the head-up CPR bundle of care.
EMS World. 2021; Supplement.
In this ebook, Dr. Moore et al. provide a brief summary of the evolution of the bundle of
sudden cardiac arrest care that is being followed by these researchers and discuss
preliminary findings from the first field uses. The bundle includes use of circulatory
adjuncts: ITD, ACD-CPR and/or mCPR used in a controlled sequence with HUP CPR
using the EleGARD. The authors answer the question, “Is this ready for prime time?”
with a resounding, “YES!” emphasizing the need for a deliberate, practiced, bundledcare
approach. They go on to discuss analysis of the first field uses which reveal that
time to deployment of the entire bundle is crucial. Just like quicker time to
defibrillation increases likelihood of ROSC, the early data for the HUP bundle shows a
similar need for rapid deployment to improve likeliehood of ROSC. The authors
provide an example of best-practice technique used by some pre-hospital providers to
reduce time to deployment, dubbed: “Carry Less, Do More.” The highest performing
agencies with quickest deployment times carry only the essential BLS equipment to
the patient’s side for initial resuscitation: AED/Defibrillator, mCPR, and the EleGARD
packaged with BLS airway equipment (SGA with an ITD and resuscitator bag). The
authors conclude, when bundled together, deployed quickly and deliberately, this
method of resuscitation is definitely ready for prime time.
5. Lurie K, Bachista K, Debaty G. The latest on the head up CPR bundle of care. Resuscitation
Brief summary of current research related to head up position CPR bundle of care. The
authors discuss current clinical practice and origin of “Carry less, do more,” the
practice by first responders of carrying only BLS items essential to the first 3-5 minutes
of resuscitation, and review findings from Moore et al data analysis that revealed
higher ROSC rates when the HUP CPR bundle was delivered quickly (≤ 10 min) and
likens this to the importance of time to defibrillation.
The authors also describe the key tenets of the HUP CPR Bundle including the need to
immediately provide high quality CPR, preferably with ACD, placing the EleGARD ASAP
and with minimal interruption, use of ITD on a sealed airway, deploying mCPR quickly,
again minimizing interruption to CPR ≤ 6seconds, priming the circulatory system
before starting the slow rise and staying on scene for a minimum of 15 minutes.
6. Moore J, Holley J, Scheppke K, Salverda B, Rojas-Salvador C, Jacobs M, et al. Abstracts for
the 2021 NAEMSP Scientific Assembly: Faster time to elevation of the head and thorax
during cardiopulmonary resuscitation increases the likelihood of return of spontaneous
circulation after out of hospital cardiac arrest. Prehospital Emergency Care 2021; 25:156.
Poster/Abstract presented at NAESMP 2021. This analysis, with 227 patients treated in 6
US sites with a HUP CPR bundle of care including an EleGARD Patient Positioning
System, an ITD-16 (ResQPOD-16), and manual ACD CPR (ResQPUMP) and/or automated
CPR with a LUCAS device, showed that when time from 911 to EleGARD placement was
< 10 min ROSC rates were 58% for all rhythms and 92% for initial shockable rhythms.
These ROSC rates were significantly higher than comparative historical data from ROC
PRIMED study. Just like defibrillation, time is of the essence with Head Up CPR. For
every minute delay in EleGARD placement after the 911 call, ROSC rates decreased by
~7% for all initial rhythms and those with a shockable rhythm.
7. Rojas-Salvador C, Salverda B, Lick M, Metzger A, Moore J, Lurie K. Abstracts for the 2021
NAEMSP Scientific Assembly: Evaluation of hemodynamic effects between a newly
developed mechanical active compression decompression cardiopulmonary resuscitation
device using an impedance threshold device during sequential elevation of the head and
thorax and conventional CPR in a swine model of cardiac arrest. . Prehospital Emergency
Care 2021; 25:151. DOI: https://doi.org/10.1080/10903127.2020.1837312
Researchers examined the use of a mCPR device with 1cm lift from the chest as part of
a HUP CPR bundle with ITD and DACSE. CerPP, EtCO2, and rSO2 were significantly
higher in the group that used the mCPR with 1cm lift, ITD, and DACSE versus C-CPR.
These findings support the use of mCPR with some active lift as part of a HUP CPR
bundle of care.
8. Duhem H, Moore J, Rojas-Salvador C, Salverda B, Lick M, Pepe P, et al. Improving postcardiac
arrest cerebral perfusion pressure by elevating the head and thorax. Resuscitation.
2021; 159:45-53. DOI: https://doi.org/10.1016/j.resuscitation.2020.12.016
This study examined the effect of HUP on post-ROSC ICP and CerPP in a porcine
model. Regardless of type of CPR provided (C-CPR vs HUP CPR with circulatory
adjuncts) or length of resuscitation, elevation of the head and thorax post-ROSC
improved ICP and CerPP and regional cerebral oximetry. No adverse effects were
observed during or after the resuscitation related to the HUP. This study provides the
first pre-clinical evidence that HUP post-ROSC provides signficant benefit, especially in
terms of lowering ICP and increasing CerPP, as long as MAP was adequate.
The authors emphasized the need for an adequate MAP into order to pump blood
’uphill’ to the elevate head, drawing the clinical parallel to the care of the traumatic
brain injured patient.
9. Moore J, Holley J, Scheppke K, Salverda B, Rojas-Salvador C, Jacobs M, et al. 2020 AHA Latebreaking
science abstracts: Faster time to elevation of the head and thorax during
cardiopulmonary resuscitation increases the likelihood of return of spontaneous circulation
after out of hospital cardiac arrest. Circulation. 2020; 142(24):e495. DOI:
Late breaking science abstract presentation at American Heart Association 2020
Resuscitation Science Symposium. Dr. Moore and others analyzed 198 out of hospital
cardiac arrest cases from 5 US sites where subjects received HUP CPR with a
combination of ACD/ITD CPR, manual/ITD CPR, or mCPR/ITD with an EleGARD™
Patient Positioning System. When this HUP CPR bundle of care was deployed within 10
minutes of 911 activation, or within 5 minutes of EMS arrival, the overall ROSC rate was
>50%. In light of this research, this group suggests considering methods for rapid
EleGARD deployment as part of this bundle. (Video presentation available upon
request: email@example.com )
10. Moore JC, Salverda B, Rojas-Salvador C, Lick M, Debaty G, Lurie K. Controlled sequential
elevation of the head and thorax combined with active compression decompression
cardiopumonary resuscitation and an impedance threshold device improves neurological
survival in a porcine model of cardiac arrest. Resuscitation. 2020a; 150-23-28 DOI:
ACD-CPR with ITD and HUP have been shown to improve both CorPP and CerPP in
several previous studies, but little is known about the neurological outcomes with this
“triple therapy” of ACD-CPR, ITD and HUP. Moore et al. applied the previously studied
method of elevating the head and thorax in a timed sequence with the use of ACDCPR
and ITD compared to C-CPR in a porcine model, monitoring hemodynamic factors
during the resuscitation and testing neurological outcomes at 24 hours. This first preclinical
look at neurological outcomes resulted in 6/8 animals in the interventions
group with an intact neurological survival (CPC of 1 or 2) versus 1 animal in the C-CPR
group surviving neurologically intact (CPC of 2). The additional 7 animals in the control
group had no ROSC or died before 24 hours (CPC of 5).
Importantly, HUP was initiated within 2 minutes of the start of CPR with full elevation
achieved by 4 minutes. Additional findings from this study replicate improved
hemodynamic factors including EtCO2, CorPP, and MAP improvements with the triple
therapy versus C-CPR. ICP and CerPP were not reported in this study to avoid possibly
altering neurological outcomes with invasive monitoring. Instead, regional cerebral
oxygenation (rSO2) was monitored and was also better in the intervention group. The
researchers highlight that the triple therapy was applied with intent, as a bundle,
reporting that no one single intervention was responsible for the good outcome.
11. Lurie K, Lamhaut L, Lick C, Heightman AJ. Proceedings from the 2nd Annual International
State of the Future of Resuscitation Conference. Journal of Emergency Medical Services.
Supplement to JEMS recapping the Take Heart America Conference in Paris, France in
October 2019. Presentations specific to HUP include:
Dr. Joe Holley: Lessons from the Dead. Use of human cadaver model to show the
effects of various interventions used during resuscitation including the positive effects
of ACD-CPR with ITD and controlled sequential elevation on ICP, CerPP, and CorPP.
Dr. Johanna Moore: Device-guided Head-Up/Torso-Up CPR. Report on consistent
laboratory findings where normal CerPP was obtained with use of ACD-CPR, ITD and
controlled sequential elevation. Dr. Moore emphasizes the need to perform this
sequence deliberately and with care, identifying several key ‘do’s and don’ts’.
The supplement concludes with two remarkable case reports using a bundle of care
that includes HUP and resulting in neurologically intact survival. The first relates the
story of a 15-year-old warm-water drowning victim who was able to return to school on
time in the Fall after his mid-summer event. The second reports on a 60-year-old
refractory ventricular fibrillation patient whose entire cardiac arrest was captured on
airport surveillance video. His recovery has been chronicled on his YouTube channel.
12. Pepe P, Aufderheide T, Lamhaut L, Davis D, Lick C, Polderman K, et al. Rationale and
Strategies for Development of an Optimal Bundle of Management for Cardiac Arrest.
Critical Care Explorations. 2020; 2:e0214. DOI:
Several dozen international resuscitation experts and practitioners joined together to
form the International Resuscitation Collaborative (IRC). They examined best practice
techniques and technologies across 10 agencies in the United States who have a 30%
higher neurologically intact discharge rate over the national average reported by
CARES. Recognizing the limitations of traditional, single-intervention studies, the IRC
looked at groups of interventions to assess the commonalities among these high
performing Systems. Their primary endpoint was neurologically intact hospital
discharge. They also used ROSC as a measure of success.
The IRC found that these agencies blend conventional and novel approaches to
resuscitation across the entire continuum of care. Highest performing agencies
focused on training and technology that improves community response, provides
professional rescuers with the tools to enhance flow and monitor quality, uses invasive
technology in the hospital and focuses on brain recovery. Common interventions
include dispatch assisted CPR, immediate chest compressions, AED use, ITD use with
SGA and ACD-CPR, m-CPR, HUP-CPR as well as ECMO and immediate cardiac
catheterization at designated resuscitation centers.
The IRC concluded that it is not a single intervention that is poised to improve
outcomes from sudden cardiac arrest, but rather bundled care that uses both
conventional and innovative techniques.
13. Moore J, Salverda B, Lick M, Rojas-Salvador C, Segal N, Debaty G, Lurie K. Controlled
progressive elevation rather than an optimal angle maximizes cerebral perfusion pressure
during head up CPR in a swine model of cardiac arrest. Resuscitation. 2020b; 150:23-28.
HUP CPR has been shown to double brain blood flow with increased CerPP during ACD
CPR with ITD. However, the optimal angle for HUP CPR is unknown. This study in pigs
was designed to compare 3 different HUP CPR angles (20 o, 30 o, 40 o) using an
automated device to deliver ACD CPR together with an ITD attached to the
endotracheal tube. CerPP, previously shown to correlate with brain blood flow, was the
primary study endpoint. Each pig was treated with HUP CPR using each of the 3
different angles, with CPR at each angle for 5 minutes, delivered in a total of 6 different
randomization sequences. No HUP CPR angle was found to be superior.
However, a follow up study demonstrated that elevating the head and the heart
starting at 20o, then progressing to 30o and then to 40o resulted in nearly normal CerPP
values and showed that controlled progressive elevation of the head and thorax during
CPR is more beneficial than an absolute angle or height to maximize CerPP. This study
therefore described the discovery of the importance of controlled sequential elevation
of the head and thorax during ACD+ITD CPR to optimize CerPP values during ACD+ITD
CPR. A follow up study by Rojas et al. (Rojas, Resuscitation, 2020, full annotated
reference above) furthered this research by identifying the optimal rate of rise during
HUP ACD + ITD CPR to achieve nearly normal CerPP during prolonged CPR.
14. Rojas-Salvador C, Moore J, Salverda B, Lick M, Debaty G, Lurie K. Effect of controlled
sequential elevation timing of the head and thorax during cardiopulmonary resuscitation
on cerebral perfusion pressures in a porcine model of cardiac arrest. Resuscitation. 2020;
149:162-169. DOI: https://doi.org/10.1016/j.resuscitation.2019.12.011
This porcine study sought to verify the optimal sequence, speed and final height for
head and thorax elevation during CPR using a comprehensive bundle of care that
includes continuous CPR with ACD+ITD-16.
They assessed an immediate rise (24 seconds) without ‘priming’ the cardio-cerebral
circuit and 2, 4, and 10-minute elevations with a period of priming in the down
position. The immediate rise protocol simulated using a transport stretcher to raise
the upper body at the waist and the controlled protocols simulated the use of a device
for controlled sequential elevation. The primary endpoint was CerPP after 7 minutes of
The 2-minute rise to a head height of 22cm and heart height of 10 cm after a 2-minute
period of priming was found to be the optimal rise time and height. A 2-minute rise
time reduced the potential harm of raising the head too quickly, as the arterial
pressure can fall, while reaching CerPP that was 50% baseline by 2.5 minutes and 80%
by 7 minutes. CorPP was also found to increase over time in the two-minute rise
group versus the immediate rise group.
An additional finding of this study was that placement on the automated head and
thorax elevation device, which raises the head to 10cm and thorax to 7 cm in the
lowest position, immediately reduced ICP by decreasing venous congestion of the
brain after receiving CPR in the supine position. The study also documented time to
first gasp, a strongly positive neuroprognosticator, with first gasp occurring 1-2
minutes sooner in the slow rise group versus the quick rise group.
These findings support the immediate placement of an elevation device under a
patient receiving CPR, a period of priming the cardio-cerebral circuit with the use of
ITD, followed by a slow progressive 2 min rise to optimize CerPP, CorPP and create an
environment that markedly improves survival with good brain function in pigs and
could lead to improved neurological outcomes.
15. Scheppke K, Pepe P, Antevy P, Lick C, Coyle C, Garay S, et al. Abstracts for the 2020 NAEMSP
Scientific Assembly: Safety and feasibility of an automated patient positioning system for
controlled sequential elevation of the head and thorax during cardiopulmonary
resuscitation. Prehospital Emergency Care. 2019; 24:100-156. DOI:
Poster presented at NAEMSP 2020. This quality improvement project reviewed
historical and post intervention data in Palm Beach County Florida where the
intervention was a patient positioning device (EleGARD). The vast majority of patients
presented with asystole or PEA. The new device was used to provide device-assisted
controlled sequential elevation of the head and thorax (DACSE) during ACD CPR with
an ITD-16, as part of an expanded cardiac arrest bundle of care. The authors reported
that use of DACSE was safe and not difficult to use. ETCO2 levels increased post
DACSE intervention to normal values in >70% of patients and the ROSC rates in
patients presenting with asystole or PEA were 44%.
16. Rojas-Salvador N, Salverda. B, Moore J, Lick M, Debaty G, Lurie K. Abstracts for the 2020
NAEMSP Scientific Assembly: Regional cerebral tissue oxygenation correlates with aortic
pressure, end tidal CO2, coronary perfusion pressure and neurological outcome in a swine
model of cardiac arrest. Prehospital Emergency Care. 2019; 24:100-156. DOI:
Poster presented at NAEMSP 2020. This research examined correlation between noninvasive
regional cerebral tissue oxygenation (rSO2) and neurologically intact survival from
sudden cardiac arrest. Swine were treated with conventional CPR in the flat position
versus device assisted controlled sequential elevation (DACSE) with an ITD-16 and
automated ACD at 100 compression/decompressions per minute. rSO2, along with
traditional monitoring parameters were monitored in both groups. Swine with higher rSO2
were found to be more likely to survive neurologically intact in both the conventional CPR
group and the DACSE ACD ITD group. rSO2 values correlated highly with ETCO2, which was
also predictive of a positive outcome. In addition, the group treated with DACSE ACD ITD
had more favorable neurological outcomes with 6/7 neurologically intact at 24 hours
compared to just 1/7 in the conventional group.
17. Lurie K, Lick C, Pepe P, Lamhaut L., Levy M, Price R, et al. State of the Future of the Science
of Resuscitation. Journal of Emergency Medical Services. 2019; March:Supplement.
Supplement to JEMS recapping the Take Heart America Conference in Oakland,
California in September 2018. Focused on current, cutting-edge science and
implementation of such including HUP for CPR, supraglottic airways for resuscitation,
ECMO, and high-performing Systems of Care.
18. Pepe P, Scheppke K, Antevy P, Crowe R, Millstone D, Coyle C, et al. Confirming the clinical
safety and feasibility of a bundled methodology to improve cardiopulmonary resuscitation
involving a head-up/torso-up chest compression technique. Critical Care Medicine. 2019;
47(3):449-455. DOI: https://doi.org/10.1097/CCM.0000000000003608
Research examined human-related factors of implementing a head/torso elevation for
high quality CPR. The body was on a stretcher that was tilted upwards about 20
degrees. Study examined >2000 out-of-hospital cardiac arrest cases over three and
half years for the safety and practical application of elevating the head and torso. They
found a bundled care approach that included high quality manual CPR followed by
CPR with the LUCAS 2.0, use of ITD, along with head and torso elevation to around 20o
using a whole body head up tilt on a stretcher, had a synergistic effect.
Survival to hospital alive rates nearly doubled from 18% to 34% for all patients. These
results were maintained well beyond initial study effect period. Impact on survival to
hospital discharge was not reported.
19. Moore J, Holley J, Segal N, Lick M. et al. Consistent head up cardiopulmonary resuscitation
haemodynamics are observed across porcine and human cadaver translational models.
Resuscitation. 2018; 132:133-139. DOI: https://doi.org/10.1016/j.resuscitation.2018.04.009
This research developed and validated a human cadaver model to assess the
physiology of HUP CPR. It showed consistent, reproducible, and significant decreases
in ICP and rise in CerPP with HUP CPR across the VF porcine model, cadaveric porcine
model and human cadaveric model. Conventional and ACD CPR plus an ITD were
studied in all three models.
20. Powell J, Dearden, K, Grayson, S. Rialto’s Resuscitation Toolkit. Journal of Emergency
Medical Services. 2017; December:28-34.
Powell et al. described their experience with the Rialto, California resuscitation tool kit.
They highlight a number of advances including HUP CPR. When uninterrupted chest
compressions, early defibrillation, de-emphasis of epinephrine, use of an ITD, and
elevating the head and thorax were combined, they found their overall ROSC rates
increased from 23% to 60%. Their ROSC rates increased from 40% to 60% with the
addition of HUP CPR. They did not report the total number of patients treated, the
hospital discharge rates or neurologically intact survival rates. The article emphasizes
the importance of a bundle of care approach to the treatment of cardiac arrest. Note
that this article was published in the Journal of Emergency Medicine (JEMS), which is
not a peer-reviewed journal.
21. Moore J, Segal N, Lick M, Dodd K, et al. Head and thorax elevation during active
compression decompression cardiopulmonary resuscitation with an impedance threshold
device improves cerebral perfusion in a swine model of prolonged cardiac arrest.
Resuscitation. 2017; 121:195-200. DOI: http://dx.doi.org/10.1016/j.resuscitation.2017.07.033
Research used microspheres to measure blood flow to brain and other organs during
prolonged (greater than 15 minutes) SUP and HUP ACD+ITD CPR. Showed doubling of
blood flow to brain with HUP ACD+ITD CPR (head and shoulders raised) versus SUP
CPR. Time to first gasp was also found to be shorter in the HUP ACD+ITD group.
Gasping may be used as a clinical indicator of improved blood flow to the brain.
22. Kim T, Shin SD, Song KJ, Park YJ, Ryu HH, Debaty G, et al. The effect of resuscitation
position on cerebral and coronary perfusion pressure during mechanical cardiopulmonary
resuscitation in porcine cardiac arrest model. Resuscitation. 2017; 113:101-107. DOI:
Examined both cerebral and coronary blood flow for supine, head up, and head down
positions at various angles initially to optimize resuscitation. Found that HUP 30
degrees optimizes cerebral and coronary perfusion in this porcine model using LUCAS
2 and ITD.
23. Ryu H, Moore J, Yannopoulos D, Lick M, McKnite S, Shin SD, et al. The effect of head up
cardiopulmonary resuscitation on cerebral and systemic hemodynamics. Resuscitation.
2016; 102:29-34. DOI: http://dx.doi.org/10.1016/j.resuscitation.2016.01.033
Research showed that elevating head and shoulders during prolonged HUP ACD+ITD
CPR but not during prolonged conventional CPR improves cerebral and coronary
24. Erich J. Heads-Up CPR: Can Elevating the Patient’s Head Improve Outcomes? EMS World.
EMS article introduced concept of HUP-CPR to prehospital providers including
highlighting early success of Palm Beach County with bundled care of HUP, ITD, ACDCPR.
PBC used a Pelican case to create a whole-body tilt. Authors and researchers
caution against this full body tilt method because of possible dependent pooling in the
lower extremities with prolonged resuscitation.
25. Debaty G, Shin S, Metzger A, Kim T, Ryu HH, Rees J, et al. Tilting for perfusion: head-up
position during cardiopulmonary resuscitation improves brain flow in a porcine model of
cardiac arrest. Resuscitation. 2015; 87:38-43. DOI:
First research article (published online in 2014) compared results of supine, whole body
30o head down or whole body 30o HUP CPR. Found that CPR performed with the
LUCAS device, ITD, and HUP provides better CerPP, oxygenation, and cerebral blood
flow compared to supine or whole body 30o head down.
II. Related Resuscitation Topics
1. Holley J, Moore J, Jacobs M, Rojas-Salvador C, Lick C, Salverda B, Lick M, Frascone RJ,
Youngquist S, Lurie K. Supraglottic airway devices variably develop negative intrathoracic
pressures: A prospective cross-over study of cardiopulmonary resuscitation in human
cadavers. Resuscitation 2020; 148:32-38. DOI:
This was a human cadaveric study assessing supraglottic airways (SGA) with different
CPR methodologies and in different body positions, including flat and HUP. The ability
to generate negative intrathoracic pressure was the primary study endpoint. Different
SGAs were compared while CPR was performed using conventional/manual,
conventional/mechanical (LUCAS 2.0), ACD and HUP ACD with and without ITD-16. The
better the airway was sealed during the decompression phase of CPR, the lower the
intrathoracic pressure. Multiple prior studies in animals and humans have
demonstrated that increased negative intrathoracic pressure during the
decompression phase of CPR improves blood flow to the heart and brain.
In the current study human cadavers received CPR with and without an ITD-16. The
study found that when an ITD-16 was used, negative intrathoracic pressures were
significantly lower during the decompression phase of CPR, regardless of the method
of CPR or the airway adjunct. Using an endotracheal tube as the gold standard, the
study found that best airway seal was obtained by iGel, air-Q®sp, and LMA-S. These
findings were similar if the body was flat or HUP, confirming it is possible to use a
variety of airway adjuncts during both flat and HUP CPR and still maintain an airway
seal during CPR.
2. Lurie K, Levy M, Swor R, Moore J. The economic impact of out-of-hospital cardiac arrest.
Journal of Emergency Medical Services. 2017; December:10-16.
Using a formula similar to that for the economic burden of motor vehicle deaths, the
cost of OHCA was assessed. Examining both direct and indirect cost to society, the
study showed the cost benefit of improving OHCA care.
3. Debaty G, Labarere J, Frascone RJ, Wayne M, et al. Long-Term Prognostic Value of Gasping
During Out-of-Hospital Cardiac Arrest. Journal of the American College of Cardiology. 2017;
70(12):1467-1476. DOI: http://dx.doi.org/10.1016/j.jacc.2017.07.782
Multicenter, randomized, controlled study. Examined prognostic value of gasping
during cardiac arrest. Found that gasping during cardiac arrest, regardless of
presenting rhythm, was associated with positive 1-year survival with good neurological
4. Segal N, Youngquist S, Lurie K. Ideal (i)CPR: Looking beyond the shadows in the cave.
Resuscitation. 2017; 121:81-82. DOI: https://doi.org/10.1016/j.resuscitation.2017.10.009.
Commentary emphasized need for bundled care approach to a multimodal problem.
Likened cardiac arrest care to care of any other complex disease. Both require new
approaches, advanced technology and pharmocology that individually offer limited
gains, but together have an expontential effect on outcomes.
5. Lurie K, Nemergut E, Yannopoulos D, Sweeney M. The Physiology of Cardiopulmonary
Resuscitation. Anesthesia & Analgesia. 2016; 122(3):767-783. DOI:
Comprehensive review of the physiology of resuscitation. Discussed components of CCPR,
identifying common errors and limitations. Introduced improvements to C-CPR
with good technique and technology including use of the ITD, ACD, and HUP.
6. Sniffing Position and Intubation
There is very little published data examining patients in cardiac arrest related to elevation
of the head and the sniffing position. Historically these patients were often excluded, as
CPR added an additional challenge to the intubation process due to the continuous
motion of the patients. Moreover, there are no randomized studies using videolaryngoscopy
in patients in cardiac arrest related to the position of the head and neck.
There are multiple studies from patients not in cardiac arrest from inside and outside the
hospital showing the benefits of the sniffing position and elevation of the head and neck.
Those studies show that first pass intubation success is higher with the elevation of the
head and neck in sniffing position.
Examples of some publications:
Murphy DL, Rea T, McCoy AM, Sayre MR, Fahrenbruch CE, Yin L, et al. Inclined
position is associated with improved first pass success and laryngoscopic view in
prehospital endotracheal intubations. American Journal of Emergency Medicine.
2019; 37:937-947. DOI: https://doi.org/10.1016/j.ajem.2019.02.038
This prehospital study showed inclined position during intubation was
associated with higher first pass success versus the flat position in a large
randomized prehospital study. However, cardiac arrest patients were excluded.
These data suggest that elevation of the head facilitates more effective
El-Orbany M, Woehick H, Salem MR. Head and neck position for direct laryngoscopy.
Anesthesia & Analgesia. 2011; 113(1):103-109. DOI:
Review of the literature noted there were limited studies on the sniffing position
and direct laryngoscopy. Those studies supported the benefit of use of the
sniffing position to improve intubation success. However, the sniffing position
did not guarantee adequate exposure of the larynx in all patients due to
anatomical difference from one subject to the next.
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III. Editorials, Commentaries and Special Reports, Including Those Showing No Potential
Benefit of Head Up Position CPR
1. Huang C CK, Lin Z, Chou Y, Chen W, Lee T, et al. The effect of the head-up position on
cardiopulmonary resuscitation: a systematic review and meta-analysis. Critical Care.
2021;25(376) doi: https://doi.org/10.1186/s13054-021-03797-x.
The authors performed a meta-analysis of current pre-clinical studies to clarify the
effects of HUP CPR versus conventional supine CPR. They compared C-CPR to HUP
CPR, analyzing primarily cerebral perfusion pressure, but also examining mean arterial
pressure, coronary perfusion pressure, and ROSC. They found 7 studies to be of
sufficient quality and without bias and addressed CerPP in C-CPR and HUP CPR.
The authors conclude that HUP CPR device by itself does not lead to better outcomes.
However, they found that a regimented process of high quality CPR with use of
circulatory adjuncts (ACD and ITD), priming the cardiocerebral circuit and providing a
slow progressive elevation yields immediate and sustained improvement in CerPP,
MAP, and CorPP. They caution that “Every factor is very important, and it would be
dangerous if any one factor is ignored.”
2. Putzer G, Wagner J, Helbok R, & Martini J. Elevation of head and thorax after return of
spontaneous circulation—A few caveats to consider. Resuscitation. [Letter to the Editor]
2021; Article in Press. http://dx.doi.org/10.1016/j.resuscitation.2021.03.036
Duhem H, Moore J, Rojas-Salvador C, Salverda B, Lick M, Pepe P, Labarere J, Debaty G, Lurie
K. Reply to: Elevation of head and thorax after return of spontaneous circulation—A few
caveats. . Resuscitation. [Letter to the Editor] 2021;Article in Press.
In their letter to the editor, Putzer et al. question the improved CerPP value in this preclinical
model of post-resuscitation care presented by Duhem et al. They note the
head up position and therefore transducer position could effect the calibration and
values. They also suggest skewed values for MAP given decreased heart function post
resuscitation. In the reply by Duhem et al., they remind readers that the fundamental
finding of this research is related to the biophysics and physiology. In both the
conventional and head up resucitation models there was significant decrease in ICP
and increase in CerPP when the post-resuscitation patient was placed in a position
similar to that of a TBI patient. They provide an elegant graphic of the tracings
obtained in their study to illustrate this. They do emphasize that research shows, in
both post-resuscitation and TBI, there must be adequate MAP to maintain this balance.
Duhem et al. also remind readers that there have been very few interventions for
cardiac arrest and post-cardiac arrest that focus on the preservation of brain function
and this pre-clinical work show promise for improved neurological function post
3. Paxton J, O’Neil B. Is ‘heads up’ the way forward [Editorial]. Resuscitation. 2020; 158:270-272.
DOI: https://doi.org/10.1016/j. resuscitation.2020.11.009
Editorial response to Moore et al. experimental paper in the same publication which
examines post-ROSC neurological outcome with a HUP new bundle of care in an
animal survival study comparing HUP CPR with C-CPR in the flat position. Paxton &
O’Brien chronicle the progression of science that led to the HUP CPR bundle of care,
lauding not only the science but the initiative to go beyond just a variation on the
current AHA guidelines. These authors state “The theory behind HUP CPR appears
sound” and that “only by questioning traditional practices, such as patient positioning
during external cardiac massage, can we hope to improve upon currently employed
methods to treat OHCA.
4. Gazmuri R and Dhliwayo N. From a toilet plunger to head-up CPR: Bundling systemic and
regional venous return augmentation to improve the hemodynamic efficacy of chest
compression [Editorial]. Resuscitation. 2020; 149:225-227. DOI:
In this editorial, Drs. Gazmuri & Dhliwayo began by noting that “prompt generation of
blood flow at levels able to reverse or at least ameliorate myocardial and cerebral
ischemia is critical for successful resuscitation from cardiac arrest. Yet, conventional
cardiopulmonary resuscitation (CPR) fails to promote more than a small fraction of
the normal cardiac output and to distribute such blood flow to the coronary and
They highlighted the use of ACD combined with an ITD as an adjunct to conventional
CPR to improve cardio-cerebral blood flow and resuscitation outcomes. They cited
research and practice that shows “bundling the ITD with ACD CPR was shown to
generate superior hemodynamic effects in animal models translating into a favorable
short-term survival in a small clinical study in Europe, and survival to hospital
discharged with intact neurological function in a larger study conducted in the USA”.
Drs. Gazmuri & Dhliwayo continued by addressing the research presented by Rojas et
al. in this same issue of Resuscitation. The Rojas study (Rojas, Resuscitation, 2020)
showed that elevation of the head and thorax in a timed sequence including a period
of ACD+ITD CPR in a low position followed by a 2-minute rise resulted in CerPP in
excess of 80% baseline with similar CorPP findings. Gazmuri et al. suggested that,
especially with no known adverse effects, it is reasonable to assume that a bundle of
care that includes ACD with ITD and sequenced HUP would likely lead to improved
outcomes in the clinical setting, especially if they can be implemented with ease and
early in the resuscitation effort.
They concluded by stating: “Dr. Keith Lurie along with his former and current
colleagues are to be credited for their sustained effort over the years in recognizing
the importance of augmenting systemic and regional venous return during CPR, with
the promise that bundling of ACD-CPR, ITD, and Head-Up CPR may lead to a
substantial improvement in cardiac resuscitation outcomes.”
5. Elphinstone A, and Laws S. Does ‘heads-up’ cardiopulmonary resuscitation improve
outcomes for patients in out-of-hospital cardiac arrest? A systematic review. British
Paramedic Journal. 2020;4(4):16-24 DOI: https://doi.org/10.29045/14784726.2020.12.4.4.16
Elphinstone and Laws published their systematic review of the literature related to
HUP CPR with the goal to try to identify the impact of this intervention in patients on
survival to hospital discharge and neurologic outcome. At the time of publication of
this review, there was one published article with human data that includes this kind of
information. That publication by Pepe et al., referenced previously in this bibliography,
was not included in their analysis. (Pepe, Critical Care Medicine, 2019).
Other human data have since been published.
The authors did highlight key findings that were consistent from multiple animal
studies. Specifically, they reported that ACD CPR with an ITD (referred to as
augmented CPR), and elevation of the head and thorax consistently lowered
intracranial pressure and increased cerebral and coronary perfusion pressures.
6. Park Y, Hong K, Shin S, Kim T, Ro Y, Song K, Ryu H. Worsened survival in the head-up tilt
position cardiopulmonary resuscitation in a porcine cardiac arrest model. Clinical and
Experimental Emergency Medicine. 2019; 6(3):250-256. DOI:
The study examined whether placement of pigs in cardiac arrest in a whole body head
up tilt at 30° angle would improve neurologically intact survival rates compared with
CPR in the flat position. Both groups were treated with a LUCAS 2.0 device and an
impedance threshold device (ITD-10) after 15 minutes of untreated VF. In the whole
body head up tilt group, the body was tilted upward rapidly after 15 minutes of VF and
then CPR was initiated. None of the head up pigs survived whereas 6/8 in the flat
This study, after it was published in abstract form, resulted in Dr. Moore et al. writing a
letter to Resuscitation entitled “Do’s and Don’ts of Head Up CPR” which is noted in this
bibliography. With the current understanding of the physiology of head up CPR, the
findings by Park et al. are predictable and not surprising.
There are several important reasons for their negative study results which should be
understood before a HUP CPR protocol is considered and implemented.
First, as previously noted in this bibliography, Kim et al. Resuscitation, 2017 and Rojas,
et al. Resuscitation, 2020, reported rapid elevation of the head and thorax without first
starting CPR in the flat position to ‘prime the system’ and start circulation will lower
the arterial pressure and reduce blood flow to the brain immediately. This is why the
arterial pressure values reported by Park et al. in their report were so low in the wholebody
head up tilt group, just 20% of those in the flat position. Rapid elevation of the
head and thorax even with CPR ongoing, has been shown to result in poorer
outcomes, as was recently reported by Rojas et al. Resuscitation, 2020. This same
research also showed a slow controlled elevation timing sequence after ‘priming the
system’ with LUCAS CPR and the ITD-16 optimizes brain blood flow and survival.
Second, prolonged elevation of the head and thorax with a whole-body tilt will result in
blood pooling in the abdomen and lower extremities over time. This physiology is
similar to what happens to alive patients with a whole-body tilt who are prone to
syncope: the blood pressure falls as blood pools in the lower extremities.
Third, an ITD-10 was used instead of an ITD-16 by Park et al. The ITD with a 16 cm of
H2O resistance prior to opening helps generate greater negative intrathoracic
pressures (to -16 cm of H2O versus -10 cm H2O) during the decompression phase of
CPR, thereby ultimately providing more blood flow to the brain. This is why the ITD-16
is used in the studies by Moore et al. and Rojas et al.
The 100% mortality after 24-hours with the Park et al. experimental model confirms the
necessity to ‘prime the pump’, elevate the head and thorax slowly, and refrain from the
whole body head up tilt position. As such, the findings by Park et al. are completely
consistent with the other studies on head up CPR, especially those by Dr. Moore et al.
7. Shaw G. Is a ‘Golden Age’ of resuscitation on the horizon. Emergency Medicine News. 2018;
Discussed recent advances that point toward the changing horizon of resuscitation
including prognostic indicators, CPR training and techniques such as extracorporeal
membrane oxygenation and head up positioning and resuscitation end-point decision
8. Strobos, NC. Debunking another CPR myth: Lay the patient flat, or head up CPR? [Editorial].
Resuscitation. 2018; 132:A1-A2. DOI: https://doi.org/10.1016/j.resuscitation.2018.07.010
Editorial addressing study by Moore, et al. in the same issue of Resuscitation. Strobos
recognized that the traditional approach of “lay the patient flat” may be wrong and
credits Moore et al. for “Debunking another CPR myth.” She discussed the challenges
of translating CPR research to cadavers. Strobos further recognized that HUP CPR is
more than just raising the head during resuscitation. She noted this should not be
done cavalierly. It is only beneficial when combined with ACD CPR and ITD in a
complete device-assisted head up CPR manner.
9. Moore J, Segal N, Debaty G, Lurie K. “The Do’s and Don’ts” of Head Up CPR: Lessons learned
from the Animal Laboratory [Letter to the editor]. Resuscitation. 2018; 129:e6-e7.
Putzer G, Martini J, Helbok R, Mair P. Reply to “The Do’s and Don’ts” of Head Up CPR:
Lessons learned from the Animal Laboratory [Letter to the Editor]. Resuscitation. 2018;
129:e8. DOI: https://10.1016/j.resuscitation.2018.06.006
Commentaries on 2018 Putzer et al. article in Resuscitation. Moore described what is
required for successful HUP CPR and what should and should not be done to get the
benefit from this new approach. Moore suggested that lack of ITD therapy in the
Putzer study could be a critical compounding factor for the neutral finding of
improved CerPP without improved cerebral oxygenation. Putzer rebutted that CerPP
should not be the only measure and conceded that a bundled care approach to cardiac
arrest is necessary especially in light of emerging technologies.
10. Putzer G, Braun P, Martini J, Niederstatter I. et al. Effects of head-up vs. supine CPR on
cerebral oxygenation and cerebral metabolism – a prospective, randomized porcine study.
Resuscitation. 2018; 128:51-55. DOI: https://doi.org/10.1016/j.resuscitation.2018.04.038
Researchers aimed to study the effect of head elevation in BLS CPR. The study
definition of BLS does NOT include the use of an ITD for circulatory support. Study
concluded that although HUP CPR decreased ICP and improved CerPP, it did not
improve cerebral oxygenation. These findings are similar to work of Ryu et al.
(referenced above) showing that HUP CPR is not effective unless circulatory enhancers
such as the ITD and/or ACD CPR are used currently. Commentaries to this article are
listed in this bibliography.
11. Wesley K, Wesley K. Tilt Angle Significantly Affects CPR. Journal of Emergency Medical
Services. 2015; 40(3).
EMS commentary on Debaty (2015) research as it applies to EMS. Presented HUP CPR
as a simple, novel approach that should be considered for incorporation into EMS
IV. Video Resources/Lectures Related to Progressive Resuscitation Technology
1. EMedHome.com. EMedHome’s Video with Johanna Moore, MD: Cutting-edge
resuscitation: Head-up CPR, eCPR, and more: Emergency Medicine News; [Dr. Moore
explores cutting-edge resuscitation, including head-up CPR, eCPR, and more]. Available
Dr. Johanna Moore presents innovations that are currently in use at Hennepin County
Medical Center and the greater Minneapolis area. At minute 5:05, she discusses the
findings from her NIH-funded studies for head-up position CPR, where near-normal
CerPP was achieved with a bundle of care including use of ACD+ITD+HUP.
2. Society of Critical Care Medicine. A 2020 Vision of CPR: Evolution, Revolution, and Novel
Solution 2019. Dr. Paul Pepe, plenary speaker, gives a talk at the 48th Critical Care
Congress]. Available from:
Plenary presentation at Society of Critical Care Medicine 2019 annual conference
discusses where CPR has come from, innovations, and new direction for resuscitation.
At minute 34:17, there is a discussion of gravity-assisted CPR and the bundle of care
needed to deploy this CPR effectively.
3. AMC Amsterdam Department of Anesthesiology. Innovations in CPR [Vimeo]. Academic
Medical Center (AMC) Amsterdam; 2018. Dr. Keith Lurie gives a lecture on innovation in
CPR. Available from: https://vimeo.com/266253707
Dr. Keith Lurie presents grand rounds to anesthesia fellows in the Netherlands on the
physiology of conventional CPR. He discusses innovations, including elevating the
head, that, when bundled together with ACD+ITD, have the potential to improve the
physiological environment for the resuscitation patient.
MKT-0034-01, Rev H., 12-21-2021