How to master CPR

EMS director and CPR aficionado Bill Reed gives a primer on High Performance CPR.

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High Performance CPR core principles

  • Rate = 110 (100-120).
  • Metronome set at 110.
  • Depth = 2.0-2.5 inches.
  • Full recoil (no leaning).
  • Focus on rate & depth.
  • Listen for 15 second countdown warning of upcoming compressor switch.
  • Change compressors at 2-minute intervals/cycles.
  • Whenever possible, compressions performed from patient’s right side and new compressor comes in from the previous compressors right side.  Opposite is true for left sided compressions.
  • New compressor to “hover” over chest during rhythm check and/or defibrillation.
  • No more than 5 second pauses for compressor change or rhythm checks.
  • Immediately resume CPR after defibrillation (no pulse checks) or when rhythm check is complete.


  • NRB or nasal cannula at max flow initially.
  • BVM when available.
  • Rate = 1 breath every 10 compressions (unsynchronized).
  • Volume = no more than ½ ambu bag.
  • ETI when feasible or if no ROSC by 6-8 minutes as resources allow.
  • ETCO2 monitor connected as soon as feasible.
  • ETI should be accomplished by a provider other than code lead.
  • Hands off patient and/or airway device at 2-minute check.


  • Attach as soon as possible.
  • Standard pad placement.
  • If witnessed VF while pads were in place for another reason, immediate charge and defibrillate.  Otherwise, ensure CPR for at least 30 seconds before delivering any defibrillations.
  • Pre-charge defibrillator 15 seconds prior to 2-minute checks.
  • If non-shockable rhythm at 2-minute check, “dump” charge by pressing the decrease energy selection button.
  • If shockable rhythm at 2-minute check, immediately defibrillate & resume CPR (no pulse checks).
  • If VF on rhythm check at 6 minutes (third cycle), immediately defibrillate, then roll patient 30 degrees towards new compressor, attach new posterior pad slightly below and medial to the patients left scapula, roll patient back and resume CPR.  Attach new anterior pad over left superior chest.  Connect new AP pads to new monitor/defibrillator.
  • At 8 and 10-minute checks (fourth & fifth cycles), pre-charge and defibrillate with new AP pads & monitor/defibrillator set at max joules.
  • At 12-minute check (sixth cycle), pre-charge both defibrillators to max joules and defibrillate both “simultaneously” if patient is still in VF.  One operator, two fingers.
  • Caveats
    • Changing to AP pads and/or double sequential defibrillation (DSD) is only for refractory VF.
    • If VF converts with standard pad placement, AP pad placement, or DSD, use that pad placement and energy setting for recurrent VF defibrillations

Venous Access

  • IO is faster than IV.
  • IV can follow IO.
  • Central venous access should be accomplished by a provider other than the code lead.


  • Know your rhythm before giving drugs!  That tachycardia might be SVT or something that might not take kindly to a bolus of epinephrine
    • Epinephrine
      • Goal is for 3 doses in first 10 minutes.
      • Can give at 2,4, & 6-minute checks or whatever time interval is most easily accomplished.
      • After 10 minutes, goal is for Epi every 5 minutes.
    • Amiodarone (for VF)
      • Goal is for 2 doses in first 10 minutes.
      • 300mg first dose and 150mg second dose.
      • Can give at 2 & 6-minute checks or whatever time interval is most easily accomplished.

Code Lead & Code Scribe/Time Keeper

  • Confirm/ensure metronome use & appropriate CPR depth & rate.
  • Confirm/ensure appropriate BVM or BV ET Tube rate and volume.
  • Confirm/ensure ETCO2 connected and documented.
  • Notify team of impending compressor change and rhythm check 15 seconds prior to the end of the 2-minute cycle.
  • Confirm/ensure defibrillator is pre-charged.
  • Interpret rhythm.
  • Instruct defibrillator operator to deliver shock (or deliver shock if code lead is the operator) after confirming no team member is touching the patient.
  • Confirm/ensure resumption of CPR and BVM after rhythm check and/or defibrillation.
  • Request and confirm drug delivery at appropriately intervals.
  • Confirm/ensure documentation of rhythm(s) and drug doses.
  • Ensure all pauses are less than or equal to 5 seconds (use 5 sec verbal count down).


  1. David Esler

    Robbie you are a great doctor and speaker. I love ER cast! That said, two musical comments: 1. Stayin Alive, Bee Gees, 1977. Rate is about 104 beats per minute. So not bad as a memory aid but a tad slow for modern upbeat CPR. 2. Kenny G. How could you even mention his name, let alone admit you dig his playing? Kenny G. is the antithesis of all the higher medical values/principles that you espouse so well on ER Cast! Jazz guitarist Pat Metheny sums Kenny G up best:

    1. Post
      Rob Orman

      Ha! As a child of the late 60s, I grew up in the disco era. Bee Gees were on regular rotation in our house and Stayin Alive is etched in my memory for perpetuity. Not that I get to do the chest compressions much these days, but that beat is what’s fixed in my mind. 104 it is.

      Regarding Kenny G, can’t fault any of the comments in the Pat Metheny interview. Chet Baker, Miles Davis, and Thelonious Monk are the type of jazz I like to listen to these days, but that one night in the winter of 1987, when I sat in the 3rd row of a Kenny G concert at the Wheeler Opera house in Aspen and watched he and his band kill it for hours and hours…. That, my friend, is also etched in my memory as the music equivalent of intravenous beta blockers and benzodiazepines. Pure pablum and effective treatment of ventricular dysrhythmias.

  2. michael estreicher

    Great discussion! thoroughly enjoyed it!
    do you have any references regarding cpr fraction, mortality rates.

    1. Post
      Rob Orman

      Here are a few from Bill Reed (the guest for the show)
      Circulation. 2009 September 29; 120(13): 1241–1247

      Crit Care Med 2012;40:1192-1198/

      Resuscitation. 2014 Jul;85(7):879-84.

      Resuscitation 2011; 82:1501-1507

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