The Race to Improve Survival: High-Performance CPR

For the past several decades AEDs and defibrillation have been the main focus of sudden cardiac arrest. CPR had lost some of its luster during that time as experts emphasized defibrillation. However, there now is an abundant evidence that shows CPR's importance in survival from sudden cardiac arrest.1-4

As a result, there's a movement sweeping the world of resuscitation called "high-performance CPR." It is pushing CPR back into the limelight as an essential tool in the resuscitation arsenal.

High-performance CPR is not a new procedure or guideline. It’s a way of applying the current CPR guidelines more effectively. The new thinking is that a resuscitation effort is more than just pushing on the victim’s chest and attaching an AED, it’s about hands-on time and teamwork.

What is High-Performance CPR?

High-performance CPR has been described as a "pit crew" approach to sudden cardiac arrest. Like a professional racing team, each rescuer has a specialized role. High-performance CPR has been described as a choreographed dance where teamwork and communication are essential.

Anyone who has practiced on a CPR manikin for any length of time knows it is physically challenging. Most people cannot perform proper chest compressions for more than two to three minutes.5-7 So it’s important to switch roles at short intervals.

Performing flawless CPR guidelines means trading places with other team members every few minutes. It is important that your team know how to quickly switch roles. Rotating chest compressors is essential to keeping the blood flowing. You need to practice timing and coordination to avoid interruptions in chest compressions.

Pit crew

Keep the Blood Pumpin'

Researchers who study resuscitation believe high-quality CPR improves the receptivity of the heart to defibrillatory shocks and emergency drugs.8 To deliver high-quality CPR you must push hard and fast on the chest to circulate oxygenated blood throughout the body. This gives the brain and vital organs enough oxygen until the heart can be re-started with a defibrillator. CPR can “suspend” death until the heart can be shocked back into a normal rhythm. CPR is not effective if compressions are not performed properly however.

In a real-world cardiac arrest, CPR often is interrupted by rescue breaths, pulse checks and heart rhythm analysis. These delays are detrimental to the effectiveness of chest compressions. This is where “practice makes perfect” comes in. By rotating rescuers as chest compressors you keep blood and oxygen flowing and greatly improve the victim’s chances of survival.

“Cardiac arrest is a chaotic event and sometimes we lose track of the fact that high-quality CPR is the cornerstone of resuscitation,” says Peter Meaney, M.D., M.P.H., assistant professor at Children’s Hospital of Philadelphia in a recent announcement by the American Heart Association.9 It boils down to following CPR guidelines to the tee.

In Depth: Coronary Perfusion Pressure

Chest compressions provide temporary circulation of blood to the brain and heart. They are only about 30% as effective as a pumping heart but that’s enough to keep the brain cells alive until a defibrillator and advance care arrives. Minor delays or interruptions to chest compressions for a short time cause coronary perfusion pressure (CPP) to go down considerably.

CPP is the amount of force that blood pushes through the coronary arteries in the heart. Once compressions are stopped it takes about a minute of resumed chest compressions to build up enough CPP to start circulating blood effectively again. Read more on chest compression fraction.

Impressive Results

EMS providers in Seattle and King County, Washington are leaders in the high-performance CPR movement. Their survival rates reached an all-time high of 57% in 2012. East Pierce Fire and Rescue District (WA) has made tremendous strides and increased survival rates from 10% to 41%. Henderson (Nev.) Fire Department has pushed up survival from 14% to 20%.

Emergency responders in the state of Michigan now are being trained in high performance CPR and it is now required of EMS personnel in Pennsylvania.

The emphasis for all these EMS providers is strict adherence to the 2010 CPR guidelines and teamwork. Other aspects of high-performance CPR addressed by these EMS systems include the addition of dispatcher-assisted CPR and quality improvement.

Although the pit crew concept of resuscitation was developed by professional responders, lay rescuers can apply the principles of high performance CPR in their training and practice.

Practice Makes Perfect

In high-performance CPR treatment must be relentless and without pause. Each rescuer has a specific responsibility. Rescue teams must practice until they can perform flawlessly and without interruption. Basic roles include: a chest compressor, a rescue breather, and an AED operator. If manpower allows, someone can monitor quality and direct role changes.

The metaphor of a racing pit crew gives responders a model to train by where no movements or actions delay the CPR. Your chest compressions must be continuous, forceful and rapid. Rescue breaths must be just one second each.

The team aims for a delivering chest compressions 90% of the time including time used up by AED analysis and shocks. The only time you should not be pushing on the chest is during rescue breaths and AED analysis and shocks. That’s a goal but the closer you are the better the odds for the victim.

Some teams have the opportunity to practice with CPR manikins that measure rate, depth and recoil. These devices give real-time feedback about whether or not you are meeting standards. The goal is perfect execution of chest compressions.

In addition to the guidelines listed above, here are some tips offered by the Resuscitation Academy for your emergency response team employ to high-performance CPR:10

  • Rotate chest compressors every 2 minutes.
  • Switch or rotate roles with minimal interruptions.
  • Hover hands over the chest during shock administration and be ready to compress as soon as patient is cleared.


Communities around the country where high-performance CPR is practiced are seeing significant increases in their survival rates. Your emergency response team can take advantage of this concept by employing the high-quality CPR measures called out in the 2010 CPR guidelines that include: minimal breaks in compressions, full chest recoil, adequate compression depth, and adequate compression rate.

A victim’s chances of successful resuscitation increase substantially when CPR is performed according to the guidelines and delays in chest compressions are minimized. New evidence shows the quality of CPR given is just as important as other treatments.

In high-performance CPR, everyone has a pre-assigned role and rescuers trade roles to maintain strict performance rates and measures. The goal is letter-perfect CPR with very few interruptions. It calls for choreographed movement and coordination between members of the emergency response team.

At this time, high-performance CPR is practiced mostly by EMTs and paramedics. But there is no reason the concept can't be applied by lay rescuers.

NOTE: AED Challenge includes a chest compression fraction value (called "CPR Percent") for each scenario to make responders aware of the importance of high-quality CPR.

View demonstration of high-performance CPR by EMS crew (external website)


1. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science: Part 1: Executive Summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Field JM, et al. Circulation. 2010;122:S640-S656,  doi:10.1161/CIRCULATIONAHA.110.970889

2. Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation. 2009;120:1241–1247

3. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA. 2005:293;305–310.

4. Wik L, et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA. 2005:293(2);305–310.

5. Ashton A, McCluskey A, Gwinnutt CL, Keenan AM. Effect of rescuer fatigue on performance of continuous external chest compressions over 3 min. Resuscitation. 2002 Nov;55(2):151-155.

6. Hightower D, Thomas SH, Stone CK, Dunn K, March JA. Decay in quality of closed-chest compressions over time. Ann Emerg Med 1995; 26/3: 300–303. 

7. Aufderheide TP, Pirrallo RG, Yannopoulos D, Klein JP, von Briesen C, Sparks CW, Deja KA, Conrad CJ, Kitscha DJ, Provo TA, Lurie KG. Incomplete chest wall decompression: a clinical evaluation of CPR performance by EMS personnel and assessment of alternative manual chest compression-decompression techniques. Resuscitation. 2005 Mar;64(3):353-62.

8. Edelson DP, Abella BS, Kramer-Johansen J, Wik L, Myklebust H, Barry AM, Merchant RM, Hoek TL, Steen PA, Becker LB. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 2006 Nov;71(2):137-45.

9. Varied quality of CPR among EMS, hospitals hurts survival. American Heart Association website. Access 10-22-13 at

10. Resuscitation Academy website. Accessed on 10/4/13 at