2023 Urban Fire Forum Position Statement

First-In Responders Providing Neuroprotective (“Heads-Up”) CPR

as the Standard of Care for Emergency Medical Services Systems

Introduction
Annually, nearly one million individuals experience sudden non-traumatic, out-of-hospital cardiac
arrest (OHCA) (1-2) in North America and Europe combined. A significant majority of these patients,
exceeding 80%, present with “non-shockable” (NS) electrocardiographic patterns, such as asystole or
pulseless electrical activity (PEA) (1-10). Despite the swift response times of our 9-1-1 emergency
medical services (EMS) systems, the immediate administration of basic cardiopulmonary
resuscitation (CPR), and other well-established advanced life support (ALS) measures, an
overwhelming majority do not survive to hospital discharge (1-12).

A small fraction of OHCA patients displaying shockable rhythms may be highly salvageable, but this
possibility hinges on specific conditions, notably early and effective CPR performed by bystanders,
coupled with rapid defibrillation within minutes (3, 6, 13-14). Nevertheless, when considering all
OHCA cases in the United States (U.S.), including those presenting with shockable rhythms, the
overall survival rate to hospital discharge was below 10% within the context of progressive EMS
systems that monitor outcomes. More notably, the rate of surviving with intact neurological function
was below 7.5% (1, 3, 5-10).

In addition to a significant number of unwitnessed events and extended response times, unfavorable
outcomes can be attributed to the inherent physiological limitations of traditional CPR. Even in cases
of shockable rhythms, early and correctly administered conventional CPR (C-CPR) only manages to
deliver approximately 20% of the normal cerebral perfusion pressure (15-21). While chest
compressions generate forward-flowing arterial pressure waves, they also generate considerable
retrograde venous pressure, resulting in pulsatile increases in intracranial pressure (ICP) with each
compression. Consequently, these elevations in intracranial pressure hinder the flow of blood through
cerebral arteries (15-21). When combined with the limited refilling of cardiac chambers, C-CPR
becomes increasingly ineffective, especially as the duration of untreated cardiac arrest intervals
lengthens (15, 16).

Nevertheless, thorough, systematic laboratory research conducted over the past decade, and ongoing
clinical investigations, have unveiled novel approaches to alleviate some of the inherent limitations
associated with C-CPR. Non-invasive CPR adjuncts, including the combined use of an impedance
threshold device (ITD) attached to breathing devices, coupled with suction cup-based active-
compression-decompression (ACD), lower intrathoracic pressure during the decompression phase of
CPR, both individually and particularly in combination (17-24). By harnessing these complementary
mechanisms, ITD/ACD-CPR effectively reduces intracranial pressure, enhances cardiac preload, and
improves coronary and cerebral perfusion pressures (15, 17, 19). In clinical trials, the combined
approach of ITD-ACD CPR has yielded a remarkable 50% enhancement in one-year survival rates
with favorable neurological outcomes compared to C-CPR (24-28).

In more recent developments, the introduction of a gradual head and thorax elevation lasting over 2
minutes (following an initial 2-minute application of ACD-ITD CPR to prime the circulation), has
consistently resulted in nearly complete restoration of cerebral perfusion pressures in laboratory
experiments. This approach has shown remarkable enhancements in neurologically favorable
survival rates, both in cases of shockable and non-shockable OHCA (17, 19, 20-23, 29-34).
Evidence, Analysis, and Rationale for Adopting This Evolving CPR Strategy
The three pivotal adjuncts responsible for achieving these harmonious physiological advantages now
include an automated head/thorax-up positioning (AHUP) device (See Appendix). These non-
invasive devices, including the ITD, ACD (both manual and automated variants), and AHUP, work in
unison to enhance the blood flow generated by conventional CPR. Importantly, they have all received
clearance from the U.S. Food and Drug Administration and are presently being introduced into
numerous clinical settings throughout the United States (22, 34, 35).
EMS early adopters of the "ITD/ACD/AHUP-CPR" protocol delivered by first responders are already
reporting significantly improved patient survival rates when assessing both shockable and non-
shockable cases together (22, 38). As in the use of an AED, the more swiftly the ITD/ACD/AHUP-
CPR combination is applied, the more favorable the outcome becomes. In general, when administered
within 10 minutes after receiving the 9-1-1 call, it is linked to a threefold higher probability of patients
experiencing neurologically intact survival, regardless of their electrocardiographic presentation.

However, the most compelling evidence comes from several studies that have demonstrated a
remarkable benefit, especially when compared to matched C-CPR controls, in patients who have a
non-shockable presentation. For instance, in the case of patients presenting with PEA, the rates of
survival with favorable neurological function reach an impressive 10%, a milestone previously
unseen. Furthermore, when administered within 15 minutes of receiving the 9-1-1 call (which
accounts for 80% of cases), the chances of surviving with intact neurological function for patients
with non-shockable rhythms (PEA or asystole) are nearly 14 times higher, even though over 70% of
these patients are found with asystole and almost half of non-shockable cases are unwitnessed arrests.

Furthermore, the prospects of achieving neurologically intact survival for patients with unwitnessed
arrests who present with asystole (a situation often viewed as futile for resuscitation efforts by most
EMS systems) are nearly seven times higher when the ITD/ACD/AHUP-CPR strategy is employed.
Although the “rates” of neurologically intact survival for these non-shockable cases predictably
remain somewhat low due to the prevalence of unwitnessed arrest scenarios and the associated longer
response times, the sheer volume of cases encountered in North America, numbering nearly 1,000
daily, suggests that using this augmented-CPR approach could potentially save tens of thousands of
functional lives annually, especially if the time taken to apply ITD/ACD/AHUP-CPR can be
consistently expedited.

Among the numerous survivors thus far, one individual, a 50-year-old seasoned EMT, unexpectedly
experienced sudden cardiac arrest and underwent an extensive resuscitation effort in St. Johns
County, FL, in June 2021. At the time of his cardiac arrest, he had been trained in the retrieval of
organs for transplantation, a role that gave him a comprehensive understanding of the various causes
of permanent cerebral brain damage. Upon regaining consciousness at the hospital, he discovered the
methods employed by the county fire rescue teams to treat him. Astonished by his remarkable
recovery, he coined the term "neuroprotective CPR" for this innovative "heads-up" technique. Thus,
the term "neuroprotective CPR" (NPCPR) was born from the perspective of a survivor who found
himself physically and mentally intact less than 48 hours after his own, albeit lengthy, cardiac arrest.
The term NPCPR was swiftly embraced by those utilizing this intracranial pressure-lowering strategy,
many of whom had personally witnessed similar successful rescues with positive functional outcomes.

While it is customary in the scientific community to advocate for traditional clinical trials for any new
intervention, it is important to note that the "proof of concept" clinical trial involving the foundational
devices (ACD-ITD CPR) had already been conducted and demonstrated robust improvements in
neuro-intact outcomes. The addition of the heads-up component has clearly amplified this effect.
Laboratory studies have consistently shown the normalization of cerebral perfusion pressures and
now the achievement of normal end-tidal CO2 levels in patients undergoing NPCPR offers strong
clinical evidence of restored blood flow (in contrast to the mere 15-20% of normal cerebral blood flow
achieved through conventional CPR alone).
Furthermore, in the context of OHCA, prominent scientists and biostatisticians have recently
endorsed the use of propensity score matching when investigating interventions. This approach is
particularly valuable in cardiac arrest studies since all the factors related to outcomes in OHCA are
already well-documented. By employing propensity scoring, researchers can optimize their analysis
while circumventing the numerous confounding variables and effect modifiers that have impacted
OHCA clinical trials. Consequently, propensity-scoring techniques are now being applied to NPCPR
studies and these have revealed remarkable distinctions in their outcomes.

Critical Role of the Fire Service in Neuroprotective CPR Delivery

Researchers initially exploring the NPCPR approach in the clinical context started to observe that the
timing of the intervention significantly influenced the outcomes. Compared to systems that provided
NPCPR equipment through paramedic ambulances only or responding supervisors, generally
resulting in some delayed arrival, EMS systems that promptly delivered the equipment through their
first responders, typically via fire suppression apparatus crews, achieved notably superior results.

In fact, the best survival rates were consistently seen in fire departments that had designed special
backpacks to expedite transport of the NPCPR equipment to the scene and then, when opened, had
resuscitation equipment strategically stored/placed in positions that would facilitate a true “pit-
crew” approach (APPENDIX). In turn, their time to application of the NPCPR devices was reduced
significantly, and neuro-intact survival rates reflected those innovative approaches developed by
the firefighters themselves.

Moreover, the NPCPR devices are non-invasive tools that can be utilized by any trained rescuer,
including firefighters, lifeguards, or other basic life support responders. A forthcoming scientific
study set to be published in the esteemed journal, Critical Care Medicine, in the upcoming months,
reveals that in more than 40% of cases, only two initial responders were responsible for applying the
devices, and in over half of the cases, three or fewer responders were involved (34).

Hence, akin to the widespread use of AEDs, it becomes evident that the majority of NPCPR
applications would preferably be administered by firefighters across the nation. Considering the
substantial number of cases they encounter, the life-saving potential of NPCPR could rival, if not
surpass, the life-saving impact of AEDs. Importantly, NPCPR not only proves more effective when
applied early, akin to AEDs, but it also extends its life-saving potential to cases with longer response
intervals. In either scenario, the fire service would once again take a leading role in saving lives.

Introducing new equipment to every response vehicle does have budgetary implications, but the costs
are not prohibitively high. The expense of the head-elevating device is less than half that of a monitor
defibrillator, and it is likely to remain operational for longer periods. Additionally, most departments
already carry mechanical suction-cup CPR devices. While the ITD costs approximately $100 per unit
used, this expenditure is relatively small compared to the overall resources currently allocated to
OHCA response. In any case, even when considering the need to procure all of this equipment, the
annualized pro-rated cost over several years remains finite and relatively insignificant when
juxtaposed with the annual expenses of operating and staffing response vehicles. Most importantly,
the return on investment in terms of improved outcomes is undeniably worthwhile.

Purpose of this Deliverable

All available data consistently point to the fact that, similarly to traditional CPR and AEDs, the more
prompt the application of NPCPR, the higher the likelihood of achieving functional survival for the
patient. What makes NPCPR exceptional is its potential to save many more patients, regardless of
whether they present with shockable or non-shockable rhythms. Considering that the neighborhood
fire station is typically the first public safety responder in the United States and other parts of the
world, the Urban Fire Forum strongly advocates that all fire departments involved in EMS should
adopt NPCPR as a standard operating procedure for managing OHCA.
Several regions in the United States are actively working on strategies to promote the widespread
implementation of NPCPR. For instance, a coalition of EMS medical directors across the state of
Florida is not only advocating for the routine use of NPCPR but is also in the process of establishing
the concept of "Resuscitation Centers" throughout the state.

Therefore, the primary aim of this position statement is to firmly recommend the widespread
adoption of NPCPR as a best practice standard of care for all firefighters involved in first response to
OHCA cases. It also serves as a preliminary guide on budgeting, training, and implementing this life-
saving strategy correctly, emphasizing the importance of avoiding incorrect implementation and
ensuring rigorous quality assurance measures.

Adopted Position and Action Items

A Suggested Framework for Implementing Neuroprotective CPR

• The Urban Fire Forum and Metropolitan Fire Chiefs will adopt the definitive position that
appropriate use and implementation of Neuroprotective CPR (NPCPR) should become the
best practice standard of care for managing out-of-hospital cardiac arrest (OHCA) with the
understanding that the fire service generally provides the first-in responders and thus would
be most likely to provide the lifesaving effect.
• The Metropolitan Fire Chiefs should align, virtually or in-person, with the Metropolitan EMS
Medical Directors Global Alliance (aka medical “Eagles”) to promulgate the critical value of
fostering NPCPR in the prehospital setting and advocate for this life-saving patient care in
systems yet to adopt such programs. A large number of the Eagles have become early
adopters and have significant experience in proper implementation.
• The Metropolitan Fire Chiefs will establish advocacy mechanisms, including virtual and in-
person conferences, to facilitate networking and mentorship for those wishing to implement
NPCPR programs and they will work alongside groups such as the not-for-profit “Take Heart
America” initiative (https://takeheartamerica.org/about-us/) which are working on strategies
to promulgate NPCPR including funding mechanisms (seed monies from donors, legislative
actions, grants and all other avenues of support) to help launch such programs nationwide.
• A manufacturer of one of the three devices used to achieve NPCPR, has a team of train-the-
trainer crews who have helped to guide program implementation across the nation, including
strategic recommendations for pit crew approaches to expedite ITD/ACD/AHUP-CPR device
placement, other patient care interventions including appropriate ventilatory techniques, and
how to facilitate accurate data collection and reporting.
• Mentorship and educational programs should be developed to address pragmatic strategies
to help overcome barriers such as budgetary considerations and accompanying justifications
as well as purchasing considerations, staggered implementation over time, and strategies for
optimal roll-out and deployment (along with training resources and receiving hospital staff
education/in-servicing and mechanisms to acquire outcome data).
• Fire services using NPCPR should participate in the Heads-Up CPR registry based at
Hennepin County Medical Center (Minneapolis, MN). Data collection should match registry
requirements.
• It should be emphasized in training and protocols that application of ITDs, ACD-CPR (manual
or mechanical), and heads-up/thorax-up elevation are not the lone tasks in terms of managing
patients with OHCA; key concomitant actions are establishing airway and respiratory support
(as indicated) while providing uninterrupted chest compressions at the right rate and depth
and with optimal recoil and minimal interruptions.
• The EMS system should identify hospitals that will optimally manage patients. Several states,
such as Arizona and Florida, have designated “Resuscitation Centers” or are in the process of
doing so, to ensure optimal management such as early cardiac catheterization or therapeutic
hypothermia as indicated.
 • It should also be recognized that heads-up/thorax CPR alone could conceivably be detrimental
if not implemented correctly or if elevating the head too rapidly without first producing
circulatory priming with the ACD-ITD devices to push the blood uphill. Therefore, any
elevation of the head and thorax needs to be performed using the ITD/ACD circulatory
adjuncts and a patient positioning device that elevates the head and thorax in a controlled and
sequential manner.

Some General Roadmaps for Proper Implementation:

1. Moore JC, Segal N, Debaty G, Lurie KG: The "do's and don'ts" of head up CPR: lessons learned from
the animal laboratory. Resuscitation 2018;129:e6-e7. doi:10.1016/j.resuscitation.2018.05.023
2. Moore JC, Pepe PE, Bachista 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;50:2-6

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________________________________________________________________

APPENDIX:

Components of Neuroprotective CPR (NPCPR) including the impedance threshold device,

a mechanical active-compression/decompression device, and an automated head and
thorax elevation device.

Specialized back-pack to facilitate rapid carriage of the equipment to the scene as well as
expedite on-scene care in a pit-crew approach with strategic placement of interventions.

_______________________________________________________________________