CPR in Prone Position

so you want to break their spine?

CPR in the prone position is just not feasible. You will not be able to compress the heart enough to do anything.

Even CPR done correctly (which it seldom is) on a supine patient is only maybe 50% as effective as the heart alone.

If you need to do CPR, you need to get them supine and on a firm surface, otherwise your wasting your time.

so you want to break their spine?

CPR in the prone position is just not feasible. You will not be able to compress the heart enough to do anything.

Even CPR done correctly (which it seldom is) on a supine patient is only maybe 50% as effective as the heart alone.

If you need to do CPR, you need to get them supine and on a firm surface, otherwise your wasting your time.

Don't you think this was a little harsh? Personally I think it's a great question given the patient's status and inability to tolerate being supine. And clearly others have had the same question given there are articles, albeit theoretical only, asking the same thing. I'm pretty sure the OP has a clear understanding of the optimal position and surface for effective CPR. There's nothing wrong with thinking outside of the box and asking questions. If you have the information/expertise to provide education in the area of question perhaps you could make an attempt to phrase it in a more constructive manner.

Nalon1 I am very well versed in CPR and ACLS. The method shown for posterior CPR involved the scapula with a sand bag or fluid bags und the breast bone for counter pressure. With this patient the action of supining them for CPR would have been pointless since we would have been circulation blood with a Po2 of approximately 35%. Have you seen this done since you seem to feel so strongly about the practice? I am looking for responses from nurses who have seen this practiced or have practiced it and what outcomes have resulted. By the way here is link to an article by the AHA which cites prone CPR. Being a nurses requires innovation and an open mind or practice will never advance.

No, I have never done it nor seen it done. I had read about it a while back and that it was considered a Class IIb option for AHA.

I did read about it a bit more just now, and still seems like too few cases to make a good justification for or against it. The few that were resuscitated were either children or adults with hyopvolemic issues where fluid replacement fixed the issue.

Hand positioning varies between studies also, some between the scapula midline (hence my break their spine comment), some just below the left scapula.

Yes innovation and being open minded is required, but so is evidenced based practice.

At a teaching facility (my facility is not one) this may be applicable, so my comment was based on personal experience and opinion.

I also look back at the legal standpoint of this. If one was to do prone CPR and the patient dies, when it goes to court, don't you think a lawyer would see that as an opportunity to say that the patient was not being taken care of correctly?

Again, teaching or research facilities are different in that aspect.

So in short, no I have not done it, not seen it, and would not do it (unless a physician specifically orders it).

Very interesting topic to me. My line of thinking is that you have 3 options when a pronated pt arrests:

1) Flip pt over... Do CPR.

2) Do CPR in prone position... And hope there is someone like OP around who has read up on the topic.

3) Do nothing, pt dies.

I think that is my prioritized order. If you have to resuscitate prone, they are already dead, so breaking the spine is a risk that may result in a life saved.

Interesting topic

No, I have never done it nor seen it done. I had read about it a while back and that it was considered a Class IIb option for AHA.

Partially correct. It is actually a Class IIb, LOE C. The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science Part 2: Evidence Evaluation and Management of Potential or Perceived Conflicts of Interest states:

Class IIb recommendations are identified by terms such as "can be considered" or "may be useful" or "usefulness/effectiveness is unknown or unclear or not well established."

From the same source as above, the AHA Levels of Evidence includes the following:

AHA Class IIB recommendation indicates that the benefit ≥ risk. Additional studies with broad objectives are needed, and additional registry data would be helpful. The procedure/treatment may be considered.

and

The class c level of evidence indicates that the "recommendations usefulness/efficacy [is] less well established" with "only divergent expert opinion, case studies, or standard of care."

Yes innovation and being open minded is required, but so is evidenced based practice.

How exactly is this not evidence based practice? The AHA addressed this issue in Part 7: CPR Techniques and Devices with the following:

When the patient cannot be placed in the supine position, it may be reasonable for rescuers to provide CPR with the patient in the prone position, particularly in hospitalized patients with an advanced airway in place

At a teaching facility (my facility is not one) this may be applicable, so my comment was based on personal experience and opinion.

Are you suggesting that only a teaching facility is capable of using evidence based practice? If not, how and why is this even an issue?

I also look back at the legal standpoint of this. If one was to do prone CPR and the patient dies, when it goes to court, don't you think a lawyer would see that as an opportunity to say that the patient was not being taken care of correctly?

Absolutely not. In light of the AHA's statement on prone position CPR it would most likely be an issue if it wasn't attempted.

As an FYI, other Class IIb, LOE C interventions listed in Part 8: Adult Advanced Cardiovascular Life Support include:

• Asynchronous ventilations and compressions after advanced airway placement
  
• Therapeutic hypothermia may be considered when the patient is comatose post ROSC
  
• The use of physiologic parameters when feasible to optimize chest compressions
  
• The use of physiologic parameters when feasible to guide vasopressor therapy during cardiac arrest
  
• The use of quantitative waveform capnography in intubated patients to monitor CPR quality, optimize chest compressions, and detect ROSC...
  
• If Petco2 is
• ... it is reasonable to consider using continuous Scvo₂ measurement to monitor quality of CPR, optimize chest compressions, and detect ROSC...
  
• ...VF/pulseless VT cardiac arrest is associated with torsades de pointes, providers may administer an IV/IO bolus of magnesium sulfate at a dose of 1 to 2 g diluted in 10 mL D₅W
  

Thanks Chare, I appreciate the information. I contacted the resuscitation council where I work to see if they would be willing to look further into this and provide information on best practice.

NThe method shown for posterior CPR involved the scapula with a sand bag or fluid bags und the breast bone for counter pressure.

This is my new thing learned for the day. I wouldn't have even been able to imagine how to do this. If you ever get to try it, please post back and let us know how it goes.

Wow...sounds like the patient should have had a DNR in place! It's a tough call, the last patient I nursed that was that unwell they nearly died every time we went near them, I imagine turning them supine would really push them over the edge. What an interesting topic.

Wow! This can be my learned something new today!! Never would I have imagined the concept! Have to credit those thinking outside the box. Although I have not worked in facilities that have had the capacity to turn our ARDS patients prone yet either. I have heard of the rotational beds, but have not gotten to actually see one. I would be very interested to learn if this is ever successful or not. It makes perfect sense if the patient could not maintain an O2 sat supine, resuscitation efforts would be useless. I have no input on the subject, but it was interesting to read about it. Thanks for posting!

Just throwing out a question. I have never had to prone a patient, much less do CPR in anything other than supine.

What would be the advantage of keeping them prone during CPR? If they are truly coding, dead is dead. One might as well flip them on their backs to do CPR in a manner that is fully supported by science, no?

However, I can see that flipping a proned patients is easier said than done considering the bed and the amount of lines that such a sick patient typically has.

Although I have not worked in facilities that have had the capacity to turn our ARDS patients prone yet either.

You haven't worked anywhere that had nurses and RTs available at the same time?

There is this myth that proning has to be done with special beds - it works just fine with regular beds, with several nurses logrolling the patient together, with somebody making sure the lines aren't getting too horribly tangled and somebody making sure the patient doesn't get accidentally extubated in the process. We don't do it terribly often at my job, but every now and then we will prone someone, and we just keep them on the same beds we always do.