High-Performance CPR: Beyond the Basics
Cardiopulmonary resuscitation is the most time-sensitive intervention in emergency medicine. High-quality CPR with minimal interruptions is the single greatest predictor of survival from cardiac arrest. The NREMT expects EMT candidates to understand not just the mechanics of CPR but the physiology behind it and how to optimize every compression.
Compression Quality Metrics
The American Heart Association guidelines specify clear targets for high-quality compressions:
- Rate: 100 to 120 compressions per minute
- Depth: At least 2 inches (5 cm) in adults, but no deeper than 2.4 inches (6 cm)
- Recoil: Allow complete chest recoil between compressions. Leaning on the chest prevents venous return and reduces coronary perfusion pressure
- Fraction: Minimize pauses. Chest compression fraction should be at least 60%, ideally above 80%
Compression-to-Ventilation Ratios
For adults with a single rescuer, use 30 compressions to 2 ventilations. For two-rescuer adult CPR, continue 30:2 until an advanced airway is placed, then switch to continuous compressions at 100-120/min with one ventilation every 6 seconds.
For infants and children with two rescuers, use 15 compressions to 2 ventilations. Single-rescuer pediatric CPR uses 30:2, the same as adults. These ratios reflect the fact that pediatric cardiac arrest is more commonly caused by respiratory failure than cardiac dysrhythmia.
AED Operation
Apply AED pads as soon as the device is available. Do not stop CPR to apply pads; one team member applies pads while another continues compressions. Place the right pad below the right clavicle and the left pad on the left side of the chest below the armpit. For children under 8 years or under 55 pounds, use pediatric pads or a pediatric dose attenuator if available. If pediatric pads are not available, use adult pads with anterior-posterior placement.
When the AED prompts "analyzing," ensure no one is touching the patient. If a shock is advised, clear the patient and deliver the shock. Resume CPR immediately after the shock without checking for a pulse. Continue for 2 minutes (5 cycles of 30:2) before the AED reanalyzes.
Special Resuscitation Considerations
Drowning
Begin with 5 rescue breaths before starting compressions. Drowning cardiac arrest is primarily respiratory, so early ventilation is critical. Do not attempt to drain water from the lungs. Continue standard CPR after initial rescue breaths.
Hypothermia
Check for a pulse for up to 60 seconds before declaring pulselessness. Cold patients may have extremely slow heart rates that are difficult to detect. If pulseless, begin CPR. Handle hypothermic patients gently to avoid triggering ventricular fibrillation. Limit defibrillation attempts and medication administration in severe hypothermia until the core temperature rises above 86 degrees Fahrenheit.
Pregnancy
Place the patient supine with manual left uterine displacement to relieve aortocaval compression. Perform compressions slightly higher on the sternum than normal. Focus on high-quality CPR and rapid transport.