[*Note from NPW, moderator: Thank you Joseph, I have included this message in our discussion on Communicating health research. I explain why in my comment at the bottom of your message.]
At the Centre for Clinical Governance Research and Patient Safety (CCGR&PS - www.hri-global.org), we had mixed emotions when we went through this article, because on one hand we were pleased that progress is being made to improve outcome for patients who suffer Out of Hospital Cardiac Arrest (OHCA) when they receive the novel Head-UP CPR (in the Traditional CPR the patient is supine), but on the other hand, we were, again, sad that while the populations in ‘high-functioning systems’ health shall benefit from this novel NP-CPR intervention, populations in lower-, low-, and middle income countries with low functioning health systems will not, for a long time, missing out on the increased chance of survival with neuro protection!.
A few points stand out for us as Take Home messages:
- when first responders use a novel CPR approach that includes gradual head-up positioning combined with basic but effective circulation-enhancing adjuncts, individuals who experience out-of-hospital cardiac arrest (OHCA) with nonshockable presentations have a better chance of survival, as shown from data from more than 2000 patients.
- the study was presented at the American College of Emergency Physicians (ACEP) 2022 Scientific Assembly, Paul Pepe, MD, medical director for Dallas County Emergency Medical Services, in Texas, reviewed data from five EMS systems that had adopted the new approach.
- Traditional CPR supine chest compression techniques, if performed early and properly, can be lifesaving, but they are suboptimal, because the 'techniques create pressure waves that run up the arterial side, but they also create back-pressure on the venous side, increasing intracranial pressure (ICP), thus compromising optimal cerebral blood flow'
- therefore, a ‘--modified physiologic approach to CPR was designed. It involves an airway adjunct called an impedance threshold device (ITD) and active compression-decompression (ACD) with a device "resembling a toilet plunger," Pepe said. The devices draw more blood out of the brain and into the thorax in a complementary fashion.
- the new technology uses 'automated gradual head-up/torso-up positioning (AHUP) after first "priming the pump" with ITD-ACD-enhanced circulation', which was found to 'markedly augment that effect even further'. 'In the laboratory setting, this synergistic NP-CPR bundle has been shown to help normalize cerebral perfusion pressure, further promoting neuro-intact survival.'
- the combination of these two adjuncts had 'dramatically improved SURV-NI by 50% in a clinical trial'
- "All of these devices have now been cleared by the Food and Drug Administration and should be adopted by all first-inresponders," "But they should be implemented as a bundle and in the proper sequence and as soon as feasible." [*see note from HIFA moderator below]
- 'Training and implementation efforts continue to expand, and more lives can be saved as more firefighters and first-in response teams acquire equipment and training, which can cut the time to response'
We also noted additional very important Take Home messages, especially for those populations in low functioning health systems: that,
i) this new 'head-up CPR cannot yet be performed by laybystanders'.
ii) "Also, do not implement this unless you are going to do it right".
Always Remember: Primum non nocere – First Do No Harm!
NOW READ ON, courtesy of MEDSCAPE:
Novel Head-Up CPR Position Raises Odds of Survival of Out-Of-Hospital Heart Attacks
By Heidi Splete October 13, 2022
Novel Head-Up CPR Position Raises Odds of Survival
https://www.medscape.com/viewarticle/982409
Prof Joseph Ana
Lead Senior Fellow/ medicalconsultant.
Center for Clinical Governance Research &
Patient Safety (ACCGR&PS)
P: +234 (0) 8063600642
E: info@hri-global.org
8 Amaku Street, State Housing &20 Eta Agbor Road,
Calabar,Nigeria.
www.hri-global.org
HIFA profile: Joseph Ana is the Lead Senior Fellow/Medical Consultant at the Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria, established by HRI Global (former HRIWA). He is a member of the World Health Organisation’s Technical Advisory Group on Integrated Care in primary, emergency, operative, and critical care (TAG-IC2). As the Cross River State Commissioner for Health, he led the introduction of the Homegrown Quality Tool, the 12-Pillar Clinical Governance Programme, in Nigeria (2004-2008). For sustainability, he established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria. His main interest is in whole health sector and system strengthening in Lower, Low and Middle Income Countries (LLMICs). He has written six books on the 12-Pillar Clinical Governance programme, suitable for LLMICs, including the TOOLS for Implementation. He served as Chairman of the Nigerian Medical Association’s Standing Committee on Clinical Governance (2012-2022), and he won the Nigeria Medical Association’s Award of Excellence on three consecutive occasions for the innovation. He served as Chairman, Quality & Performance, of the Technical Working Group for the implementation of the Nigeria Health Act 2014. He is member, National Tertiary Health Institutions Standards Committee of the Federal Ministry of Health. He is the pioneer Secretary General/Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. Joseph is a member of the HIFA Steering Group and the HIFA working group on Community Health Workers. (http://www.hifa.org/support/members/joseph-0 http://www.hifa.org/people/steering-group). Email: info AT hri-global.org and jneana AT yahoo.co.uk
[*Note from NPW, moderator: The article says: "All of these devices have now been cleared by the Food and Drug Administration and should be adopted by all first-in responders." But, let's be careful here. Who is saying this? It is Pepe, the lead author of the research. In my view researchers should focus on communicating the results of their research, and not on making major policy recommendations. It is reasonable to say "Our results suggest that this method requires further exploration as a potential alternative to current CPR procedure". But I feel it is overstepping the role of a researcher to say everything "should" now change. Such change needs to be considered by the cardiovascular research community as a whole, taking into account all available evidence. Furthermore, I have checked the study itself - https://www.annemergmed.com/article/S0196-0644(22)00609-6/fulltext#relatedArticles - and it appears to be available only as an abstract. Indeed, it seems to be the abstract of a paper given at a conference. Furthermore, the authors disclosure statement says "Advanced CPR Solutions; Board Member/Officer/Trustee Advanced CPR Solutions' and at the end of the article it sates that the research was partly funded by Advanced CPR Solutions. Advanced CPR Solutions. It is also notable that the abstract itself does not say 'should be adopted by all first-in responders'. This is what the journalist wrote, apparently reporting what Pepe had said verbally at the conference.
I think this case provides a good case study to explore the potential distortion that can take place when research is communicated. Pepe's 'novel' (it is amazing how often this word is used in the conference's several hundred abstracts) procedure may or may not contribute significantly to the cumulative knowledge on CPR - it is FAR too early to tell. I invite comments on the above. Neil PW]
