Effects of head-up CPR on survival and neurological outcomes: A systematic review

The impact on survival and neurological outcomes of head-up cardiopulmonary resuscitation (CPR) remains unclear. This systematic review aimed to examine whether head-up CPR or head-up CPR bundle affects survival and neurological outcomes.

In this review registered in PROSPERO (CRD42024541714), we searched Medline, EMBASE, Scopus, Emcare and Cochrane library from inception to February 12, 2025. The inclusion criteria were studies: in adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest, comparing head-up CPR or head-up CPR bundle with standard or compression-only CPR in supine position, and randomized controlled trials (RCT) and observational studies. We excluded non-human studies and used Cochrane's Risk of Bias-2 and ROBINS-I tools for risk of bias assessment, and GRADE for outcome assessment. We conducted a narrative synthesis of the findings.

We identified four observational studies with 10,099 participants and no RCTs. All outcomes were judged to be very-low certainty of evidence, subject to high-risk of bias. Two pre- and post-intervention studies showed no statistically significant difference in survival with a good neurological outcome. The other two studies, which analyzed overlapping cohorts comparing the head-up CPR bundle with conventional CPR, showed mixed results-one found no statistically significant difference in survival to hospital discharge with favorable neurological status, while the other, focusing on patients with nonshockable rhythms, found that the head-up CPR bundle was associated with increased survival with favorable neurological function.

The available evidence remains limited, highlighted by the absence of RCTs or observational studies with adequate comparisons.