Enhanced CPR – From EMCrit Podcast #69

When sudden cardiac arrest occurs, immediate high quality bystander and then continuing high quality EMS-ED CPR vastly increases the patient’s chance for neurologically intact survival.

And the Basic Life Support Course and Protocols and the Advanced Cardiac Life Support Course And Protocols are the foundations on which  we build our CPR care.

Dr. Weingart of EMCrit gives four outstanding podcasts that review the current state of cutting edge CPR.

My post today covers #69 about Enhanced CPR (the system mentioned in the podcast is now commercially available as the Zoll ResQCPR).

Dr. Weingart’s four podcasts are:

EMCrit Podcast 69 – The Future of CPR with Keith Lurie and Demetris Yannopoulos [Link is to the show notes and podcast]. March 19, 2012 by Dr. Scott Weingart

Podcast 125 – The New Intra-Arrest (Cardiac Arrest Management) [Link is to the show notes and video podcast.] June 2, 2014 by Dr. Scott Weingart.

EMCrit Podcast 130 – Hemodynamic-Directed Dosing of Epinephrine for Cardiac Arrest [Link is to the show notes and podcast] August 10, 2014 by Dr. Scott Weingart.

EMCrit Podcast 191 – Cardiac Arrest Update [Link is to the show notes and podcast]
January 23, 2017 by Dr. Scott Weingart.

Each of the above podcasts and show notes need to be reviewed carefully to get everything out of them. And be sure to read all the listener comments and questions – Dr. Weingart’s listeners are incredibly thoughtful clinicians. My notes below on Podcast #69 are simply my medical notes (a part of my peripheral brain which is my blog).

In EMCrit Podcast 69 – The Future of CPR with Keith Lurie and Demetris Yannopoulos, the speakers discuss enhanced CPR, “stutter” CPR to prevent reperfusion injury in a porcine CPR model, and the use of nitroprusside and adenosine also in a porcine CPR model.

Enhanced CPR consists of two components, a special CPR device and and an impedance threshold device both designed to work together to increase cardiac output during CPR. A large study was published in the Lancet (1):

ACD-CPR was performed with a hand-held device consisting of a suction cup attached to the chest, a handle, audible metronome set to 80 times per minute, and force gauge to guide compression depth, and chest wall recoil.15,16 The ACD-CPR requires the operator to compress to the same depth as S-CPR and then lift upward to fully decompress the chest. 15,16 An ITD, with an inspiratory resistance of 16 cmH2O and < 5 cmH2O expiratory impedance, was connected to a facemask and/or advanced airway. The ITD lowered intrathoracic pressure during the decompression phase of ACD-CPR by allowing periodic positive pressure ventilation while impeding passive inspiratory gas exchange during chest recoil phase.10, 17 Both the ACD-CPR device (ResQPump,® also called CardioPump®) and the ITD (ResQPOD®) were manufactured by Advanced Circulatory Systems, Inc. (Roseville, Minnesota, USA).

In conclusion, compared with standard CPR, ACD-CPR with augmentation of negative intrathoracic pressure resulted in significantly increased survival to hospital discharge with favorable neurological function. One year after OOHCA, survival rates with similar neurologic functionality were also significantly higher in the intervention group.

In 2015, the enhanced CPR system described above was approved by the FDA and brought to market by Zoll. (2) (3)

Part 6 of the AHA guidelines,  Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation (4), states:


Conventional CPR consisting of manual chest compressions interspersed with rescue breaths is inherently inefficient with respect to generating significant cardiac output. A variety of alternatives and adjuncts to conventional CPR have been developed with the aim of enhancing cardiac output resuscitation from cardiac arrest. Since the 2010 Guidelines were published, a number of clinical trials have provided new data on the effectiveness of these alternatives. Compared with conventional CPR, many of these techniques and devices require specialized equipment and training. When rescuers or healthcare systems are considering implementation, it must be noted that some techniques and devices have been tested only in highly selected subgroups of cardiac arrest patients.

  • The routine use of the impedance threshold device (ITD) [By Itself] as an adjunct to conventional CPR is not recommended.
  • A recent randomized controlled trial suggests that the use of the ITD plus active compression/decompression CPR [The Zoll ResQCPR System (3) is associated with improved neurologically intact survival for patients with OHCA. [Emphasis Added – The Zoll ResQCPR System is approximately $1400]
  • The routine use of mechanical chest compression devices is not recommended, but special settings where
    this technology may be useful are identified.
  • The use of ECPR may be considered for selected patients in settings where a reversible cause of cardiac
    arrest is suspected.

Additional Resources:

(1) Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Lancet. 2011 Jan 22;377(9762):301-11. doi: 10.1016/S0140-6736(10)62103-4.

(2) ResQCPR System Approved by FDA. First and only CPR adjunct ever approved – blog post of March 13, 2015 from Dr. Smith’s EKG blog.

(3) Zoll ResQCPR System Product Information (Accessed 3-6-2017):

The ResQCPR™ System is a CPR adjunct that consists of two synergistic devices—the ResQPOD® ITD 16 and the ResQPUMP® ACD-CPR device. Together, they increase the likelihood of survival. A major clinical study of more than 1600 patients showed a 49% increase in one-year survival from cardiac arrest.*

  • The ResQPOD ITD 16 returns more blood to the heart (preload) and lowers intracranial pressure by regulating airflow during CPR to increase the vacuum in a patient’s chest during chest wall recoil.1,2
  • The ResQPUMP ACD-CPR device further increases blood return by re-expanding the chest with a lift force of up to 10 kg. It is the only approved system for delivering true active compression-decompression CPR.

(4) Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary
Resuscitation: Web-based Integrated 2010 & 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [Full Text PDF] (Accessed 3-6-2017)

(1) Trick of the Trade: Pre-Charge the Defibrillator By: Sam Ghali, MD from Academic Life In Emergency Medicine. May 16th, 2016

(2) Zoll See-Thru CPR:

See-Thru CPR® technology filters out compression artifact on the ECG monitor so that rescuers can see the underlying heart rhythm during cardiopulmonary resuscitation (CPR), thereby reducing the duration of pauses in compressions.

(3) How To Put On the Lucas With Minimal CPR Interruption, brief video from Dr. Weingart of EMCrit.

(4) CPR induced consciousness: It’s time for sedation protocols for this growing population, [PuMed Abstract] [Full Text PDF]. Resuscitation. 2016 Jun;103:e15-6. doi: 10.1016/j.resuscitation.2016.02.013. Epub 2016 Mar 5. Here is the Sedation Protocol For CPR Induced Consciousness:

(5) The Physiology of Cardiopulmonary Resuscitation [PubMed Abstract] [Full Text PDF]. Anesth Analg 2016;122:767–83

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