Prone CPR: When Supine Positioning Isn’t Possible

Bystander CPR is a critical element in saving lives from out-of-hospital cardiac arrest. This much is clear. Dispatch-assisted CPR can double or even triple the chances of survival following OHCA.

However, strict emergency medical dispatch (EMD) protocols don’t always allow for confounding factors such as patient positioning and access. What if grandma finds grandpa face down between the bathbub and sink and can’t flip him over?

In these events, dispatchers have to allow for sound reasoning and clinical judgment, said Ryan Jacobsen, MD, FACEP, FAEMS, during his talk “Is Prone CPR an Effective Tool for Dispatchers?” April 28, 2022 at the IAED Navigator Conference in Nashville.

Jacobsen co-authored a recent article in Prehospital Emergency Care that examined two cases of prone dispatch-directed CPR and their outcomes.

Prone CPR

Jacobsen is EMS medical director for the Johnson County EMS System in Kansas. He explained that placing patients into prone positions has been occurring in ICU settings for years to open airway passages. But prone CPR remains an uncommon event in the prehospital setting.

In theory, CPR compressions will deliver the same mechanism of action on hemodynamics whether the patient is chest-up or chest-down, said Jacobsen. Limited studies on manikins and recently deceased human subjects have supported this hypothesis, but to date there remains little evidence beyond case reports of the success of prone CPR in the prehospital setting. The American Heart Association recommends prone-positioned CPR for hospitalized patients with an advanced airway in place when supine positioning isn’t possible, but stops short of any recommendations in the out-of-hospital setting.

“EMS is still the Wild Wild West” regarding prone CPR protocols, said Jacobsen. “There’s not a lot of evidence about what we’re doing in the field.” But rare cases with successful outcomes are raising interest and asking questions.

Of course, ventilation ability is compromised in prone patients, said Jacobsen, though the prone position may alleviate the problem of the tongue falling back into the throat while unconscious. Some theories propose that placing the patient’s forearm under their forehead can help open the airway. One comment from the audience added that the danger of choking while vomiting could be lessened as well.

Recommendations and Takeaways

Prone CPR is still in the “observation/question” phase of the scientific method, said Jacobsen. Hypotheses, experimentation and conclusions have not happened yet. For this reason, researchers and industry associations are a long way from recommending prone CPR in the field or building it into EMD protocols.

Takeaway points and questions that Jacobsen stressed to his audience included:

• CPR saves lives;
• How much time is wasted with no blood flow in trying to position a patient supine? Is limited circulation preferable to none?
• Consider the quality of compressions delivered by elderly bystanders;
• Supine if you can; only consider prone if it’s not possible.

To help illustrate his session, Jacobsen played 9-1-1 recordings in which callers reported that patients were either too large or positioned in a way that it was impossible to roll them into a supine position. He touched on the controversy and potential downsides of prone CPR as well—i.e., are lower-quality compressions leading to worse long-term neurological outcomes? These are points to consider, he stressed.

Jacobsen concluded by saying the medical and lay public have little idea what dispatchers do and are capable of. “What you guys do is so important,” he said, adding that the role of telecommunicator-assisted CPR is a critical link in the chain of survival. “Your job is so important in saving lives.”