What are the Essential Elements of High Performance CPR?

Adult High Performance CPR (HP-CPR) Demo at the South Carolina Resuscitation Academy!

Hilton Head Island Fire Rescue: Tim Santini, Jon Ceiply, Shane Marstiller, Sean Kavlick

What is High Performance CPR?

High Performance CPR typically consists of expertly performed BLS with strict attention to:

Minimally interrupted chest compressions

  • Ensuring optimal rate (100-120)
  • Ensuring adequate depth (2 – 2.4″ or 5 – 6 cm)
  • Allowing full chest recoil (avoid leaning)
  • Rotate rescuer on compressions every 2 minutes

Controlled ventilations

  • Only enough for chest rise (300 – 400 ml)
  • Pausing only 2-3 seconds to ventilate during 30:2
  • Asynchronous ventilations every 6 seconds once advanced airway is in place or every 10th compression


  • Shocking on a 2-minute cycle
  • Pre-charging the monitor at 1:45
  • Minimize perishock pause to less than 5 seconds
  • Change out rescuer on chest compressions during perishock pause

This is essentially “The Seattle Way” but there are variations even within the Medic One system. They also practice what is called “BLS Continuous” which consists of continuous chest compressions with a ventilation interposed every 10th chest compression.

Minimally Interrupted Cardiac Resuscitation (MICR)

In Arizona they practice Minimally Interrupted Cardiac Resuscitation (MICR) — also known as Cardiocerebral Resuscitation (CCR) — for adult non-asphyxial arrest (important caveat) which consists of up to 4 cycles of continuous chest compressions with passive oxygen administration.

To argue about which approach is “better” misses the point until we have evidence that is definitive. Whatever method you employ, be an expert in that method and measure outcomes. That’s how we know what works and that’s what makes something “high performance.”

The science of resuscitation is always evolving. The idea is to develop a culture of continuous quality improvement. That’s easier said than done but it’s a worthwhile endeavor!

Establishing baseline performance at CPR University at the University of Arizona College of Medicine.

The 2015 AHA ECC Guidelines state: “For adults in cardiac arrest who receive CPR without an advanced airway, it may be reasonable to perform CPR with the goal of a chest compression fraction as high as possible, with a target of at least 60%.” This figure is surprisingly low. With HP-CPR the chest compression fraction can easily be over 80% and frequently over 90%.

To develop the correct muscle memory we strongly encourage the use of instrumented manikins. It’s the best way to perfect chest compressions and ventilations.


Kleinman M, Goldberger Z, Rea T et al. 2017 American Heart Association Focused Update on Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardio pulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2017:CIR.0000000000000539. doi:10.1161/cir.0000000000000539.

Ewy G. Cardiocerebral and cardiopulmonary resuscitation – 2017 update. Acute Medicine & Surgery. 2017;4(3):227-234. doi:10.1002/ams2.281.

Kleinman M, Brennan E, Goldberger Z et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality. Circulation. 2015;132(18 suppl 2):S414-S435. doi:10.1161/cir.0000000000000259.

Nichol G, Leroux B, Wang H et al. Trial of Continuous or Interrupted Chest Compressions during CPR. New England Journal of Medicine. 2015;373(23):2203-2214. doi:10.1056/nejmoa1509139.

Vaillancourt C, Everson-Stewart S, Christenson J et al. The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillation. Resuscitation. 2011;82(12):1501-1507. doi:10.1016/j.resuscitation.2011.07.011.

Christenson J, Andrusiek D, Everson-Stewart S et al. Chest Compression Fraction Determines Survival in Patients With Out-of-Hospital Ventricular Fibrillation. Circulation. 2009;120(13):1241-1247. doi:10.1161/circulationaha.109.852202.

Further Reading

Pit Crew / High Performance CPR – The Explicit Details

High Performance CPR – Performance Not Protocol!

CPR First? Or Defibrillation First?

Seattle / King County Resuscitation Academy (Free Resources With Registration)


  • Max says:

    I was wondering about the lack of defibrillation right at the beginning of the code when the pads were applied and in the Arizona Approach. Is there a specific reason for this? Defibrillation is more or less the only efficient prehospital treatment of Vfib and VT. ERC guidelines reccomend defibrillation of these rhythms as soon as possible. I would love to hear your thoughts. Greetings from Germany!

    • Tom Bouthillet says:

      This is based on what is taught in the Seattle / King County Resuscitation Academy. Yes, you can shock right away (but perform chest compressions while defibrillator is being deployed). The ROC PRIMED trail showed no difference in outcomes between shocking as soon as possible and a prescribed period of CPR (typically 90-180 seconds) before the first shock. On the other hand, a meta-analysis showed that high performing systems with witnessed VF survival > 20% did better with an “analyze late” strategy of CPR prior to the shock. In my department we shock as soon as possible and the first 2-minute cycle begins after the first shock. Even so, it usually takes 1-2 minutes to get the first shock on board according to our surveillance data. There is a good discussion about it here: https://www.aclsmedicaltraining.com/blog/cpr-first-defibrillation-first/

  • J. L. Papietro (Jonathan) says:

    Technology for the sake of technology is not progress, manikins with visual/audible feedback (… as I used in my first EMT/CPR class 25 years ago) are useful, but only to learn technique and understand the principles of cardiovascular resuscitation.
    I have been teaching AHA CPR/First Aid classes for 25 years and have presented a 3 – step manual instruction, with a simple graphic of my own design, to complement AHA/CPR guidelines.
    The focus of this instruction is efficiency, which was a cornerstone of CPR before someone though of calling it “High Performance/Quality CPR”.
    If you are interested in my visual image technique, send me your telephone number, we will talk.

  • We transitioned back to a quick look and shock as soon as the pads are applied (while not delaying CPR and continuing while charging). We have maintained a continued focus on high-performance CPR since initiating We’re a fairly busy system and our Utstein rate has been 65+ and 50+ over the past couple of years.

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