The following article is written by David Grovdahl, MS, NRP is an EMS director and advocate for rural EMS systems. He has been a paramedic for 18 years and lectures frequently on topics ranging from data analysis to system design and the integration of technology in rural areas.
The 5 Components of High Quality CPR
Not that long ago, professional rescuers were taught to push hard and fast when treating victims of cardiac arrest. That’s all you needed to ensure you were doing good chest compressions, or so you were taught. The 2015 American Heart Association (AHA) and European Resuscitation Council (ERC) Guidelines continue to raise the bar on what’s required to provide life-saving CPR. High-quality CPR Defined In the 2015 Guidelines, the AHA describes high-quality CPR as the combined impact of 5 factors:
1. • Depth: 2–2.4 inches (5–6 centimeters)2. • Compression rate: 100–120/minute3. • Recoil: Allow for full recoil after each compression. No leaning.4. • Minimize pauses. Get the chest compression fraction (CCF), the percentage of time CPR is being delivered, as high as possible, with a target of at least 60%. It may be reasonable with a sufficient number of rescuers to achieve a CCF greater than 80%.
5. • Ventilation: 2 breaths after 30 compressions without an advanced airway; 1 breath every 6 seconds with an advanced airway.
These metrics represent our best description of the type of CPR that is likely to result in a good outcome for patients. Each factor contributes to patient outcomes and needs to be monitored, recorded, and reviewed for continuous quality improvement.
One of the significant changes in the 2015 Guidelines was establishing an upper limit of 2.4 inches for compression depth and more specific guidance on rate: 100 to 120 compressions per minute, compared with >100 in the 2010 Guidelines.
High-quality CPR is cardiopulmonary resuscitation that meets performance metrics set by international resuscitation guidelines. When a patient in cardiac arrest receives high-quality CPR, their chances of survival and neurological outcomes improve. In fact, high-quality CPR makes it up to four times more likely that a victim neurologically recovers.
Always remember to ensure the scene is safe and call 911 before starting CPR. If you can deliver chest compressions while you or a fellow rescuer is on the phone with 911, that is great. Otherwise, if you are alone and need to leave to access a phone, prioritize calling 911 over starting CPR.
Dr. Benjamin Abella, Director, Center for Resuscitation Science, U Penn, describes the importance of high-quality CPR and how it directly impacts SCA outcomesComponents of High-Quality CPR
In 2020, based on updates to the international CPR guidelines, the AHA released updated guidelines on how to deliver high-quality CPR to adults. These guidelines offer four main metrics to meet to ensure the CPR you give to adult victims is as safe and effective as possible. Let’s take a closer look!
1. Safe, Supportive Positioning and Location
During CPR, your hands must be placed appropriately to ensure accurate and safe chest compressions. You should place the heel of one of your hands in the middle of the victim’s chest toward the bottom third of their sternum. Fold your other hand over the top, interlacing your fingers to create a good grip.
If you can perform CPR safely where the victim is found, do not move the victim. Ideally, you will perform CPR on a firm surface and the victim will be on their back.
2. Compression Rate and Depth
The recommended compression rate for high-quality CPR is between 100 and 120 compressions per minute. Rates above or below this range reduce the chances of survival of the victim.
The American Heart Association has developed a playlist to help people remember the correct rate for chest compressions, by using the beat of a familiar song! All of the songs in this playlist are between 100–120 beats per minute.
When delivering compressions, the amount of time you spend compressing the chest and allowing it to recoil should, ideally, be equal. Leaning on the chest should be avoided between each compression.
A person performing CPR should compress the adult victim’s chest to at least two inches, but no more than 2.4 inches. For prepubescent children and babies, the compression depth should be 1.5 inches (4 cm) in infants to 2 inches (5 cm) in children. When doing CPR, focus on getting the compressions down to the correct depth.
3. Chest Compression Fraction, Rescue Breathing, and Pauses
Chest compression fraction (CCF) is the proportion of CPR time spent providing compressions during a cardiac arrest event. When performing CPR, you need to minimize any pauses in chest compressions to have adequate CCF. The AHA recommends a CCF of at least 60%. That means you are spending 60% or more of the time delivering compressions. If you give rescue breaths, any pause you make for delivering them should be as short as possible, bearing in mind that according to the AHA each rescue breath should last 1 second.
When someone is in cardiac arrest, usually the blood oxygen levels are sufficient for at least 3-5 minutes, and perhaps longer. However, their blood needs help circulating what oxygen they do have and need to their organs and tissues. When compressions are interrupted for too long, there is not enough blood flow to deliver oxygen to important organs and tissues.
According to the American Heart Association, the recommended compression-ventilation ratio for one or two rescuers for an adult is 30:2. This ratio is the number of compressions (30) and breaths (2) during one cycle of CPR.
4. AED shocks
If you gain access to an AED before medical personnel arrive on the scene, make sure to turn it on and follow its prompts to deliver safe, effective shocks to the victim as soon as possible.
Learn how to use an AED
High-Quality CPR Steps
There are some differences in how to administer CPR, depending on the person’s age or size. Infants, Children, and Adults each have different CPR requirements.
Here are the Key Steps for Providing High-Quality CPR:
- Make sure the scene is safe for you and the victim.
- Check breathing and responsiveness. If there is no breathing, or only unusual gasping, and the person is not responsive, the person requires CPR.
- Call 911! If you are alone, find a phone and call. If someone is with you, tell them to call 911 while you begin CPR. You can also call from your cell phone on speakerphone as you begin compressions.
- Push! Start compressions. Hands-only CPR (that is, continuous chest compressions without rescue breaths), even if it’s not performed perfectly, greatly increases a person’s chances of survival. If you are willing, able, or trained in CPR, provide rescue breaths at a rate of two breaths for every 30 compressions during one cycle of CPR. Remember to keep pauses to compressions as short as possible and do not over ventilate the patient. If you aren’t willing or able to do rescue breaths, you can still jump in and help by providing hands-only CPR, which will still greatly improve the victim’s chance of survival.
- After initiating high-quality CPR, the next thing you would need to do is administer a shock. When an AED arrives, deliver a shock if needed.
- Continue CPR until prehospital providers arrive.
5 common CPR mistakes to avoid
1. Rescuer Exhaustion
Providing the proper compression depth at the proper rate can be exhausting. When rescuers become exhausted, they can deliver compressions that are too shallow or too slow. They can also lean too heavily on the victim, blocking complete chest recoil. When two or more rescuers are available, the AHA recommends switching off who does compressions every two minutes, which is about 5 cycles of 30 compressions and 2 rescue breaths.
2. Leaning on the Victim Too Much
You need to take your full weight off of the victim between compressions. The chest needs to recoil fully between compressions. Complete chest recoil is essential because it allows the chest to fully expand, which creates negative pressure that pulls blood back into the chest and cardiac tissues. Drawing blood back into the chest allows for the heart to get the oxygen it needs to survive the ordeal. Leaning or keeping pressure on the chest between each compression is the main cause of incomplete chest recoil and will actually decrease blood flow, reducing the quality of CPR.
3. Mistiming Chest Compressions Around AED Shocks
Make sure your hands are clear from the victim when delivering an AED shock so you can avoid being shocked yourself. However, the gap between when your compressions end and when the shock is delivered should be as short as possible. Similarly, you should resume compressions as soon as is safe after delivering an AED shock.
4. Checking for A Pulse
The AHA only recommends that healthcare workers check for a pulse. If you are a lay rescuer, whether you are trained or not, you should not waste time checking for a pulse if someone is unresponsive. This is because it is difficult to tell if someone has a pulse or not during a medical emergency, and it is easy to get it wrong and waste precious time.
5. Overemphasis on Rescue Breaths
Bystanders should do compression-only CPR if they are unable, untrained, or unwilling to provide rescue breaths. According to the AHA, if you see an adult suddenly collapse you should—at a minimum—call 911 and provide high-quality chest compressions by pushing hard and fast in the center of the chest, minimizing interruptions. The AHA emphasizes chest compressions over rescue breaths, since the circulation of oxygen to vital organs is more important than delivering more oxygen to the victim.
Conclusion
High-quality CPR saves lives! In fact, according to the American Heart Association, high-quality CPR is one of the most important factors to improve the chance of survival from cardiac arrest.
FAQ
Take a look at some common questions we see about high-quality CPR.
All people suffering from Sudden Cardiac Arrest (SCA) require high-quality CPR! SCA can occur in people of all ages and can occur at any time. High-quality CPR increases the chances of a person surviving, and leaving the hospital without lasting damage to their heart or brain.
Allowing complete chest recoil allows the chest to fully expand, which creates negative pressure, pulling blood back into the chest and cardiac tissues. Drawing blood back into the chest allows the heart to get the oxygen it needs to survive the ordeal.
Children require chest compressions at the same rate as adults. The main difference is the force needed on the chest. If the child is young or small, you may only need to use one hand to press down one and a half inches into the chest. Older and larger children may need two inches of depth compression.