High-Quality CPR

Why this matters

The compression rate drifts during a real resuscitation. Someone leans on the chest. Someone stops compressions to argue about the strip. Measure the work instead. Use the right rate, the right depth, full recoil, short pauses, and breaths that are not too fast. Drugs and tubes do not outrank that.

Clinical sequence

1. Confirm arrest. Start compressions where you found the patient if you can do high-quality CPR safely. Use the rate, depth, recoil, and pause limits below. Do not rush a move that pauses the chest.
2. Put the pads on. If the rhythm is VF or pVT, shock, then put hands back on the chest at once. VF means ventricular fibrillation. pVT means pulseless ventricular tachycardia.
3. Switch the compressor about every 2 minutes. Do not watch the screen instead of compressing.
4. Start with an IV in adult arrest. Use IO if the IV fails or is delayed. Use the same dose you would give by IV, then flush. Work the airway at the same time. Do not stop CPR for a perfect tube.

Adult CPR Pieces

• The rate is 100 to 120 compressions a minute. Do not push at 90, and do not push at 140.
• In adults, the depth is at least 5 cm (2 in). Push hard enough to reach that depth. Avoid shallow compressions. Older training also warned that too much depth can injure. Follow your training materials. Do not invent a depth limit.
• Let the chest come all the way back. Get your weight off the chest. Leaning on the chest blocks filling of the heart.
• Keep pauses under 10 seconds. Aim for compressions during at least 60 percent of the resuscitation. Switch the compressor about every 2 minutes.
• Until an advanced airway is in place, use 30 compressions and 2 breaths for adults, with one or two rescuers.
• Once an advanced airway is in place, do not pause compressions. Give 1 breath every 6 seconds, about 10 breaths a minute. Look for chest rise. Do not over-bag.
• If there is a pulse but no breathing, give 1 breath every 6 seconds, about 10 breaths a minute.
• AHA 2025 teaching is to stay and work the arrest where you found the patient when high-quality CPR can be done safely. Move for a reason. The scene is unsafe, you cannot ventilate, or you need the ambulance for the next shock or for transport. Do not move just to load and go.
• Routine use of a mechanical CPR device is not recommended. It is a logistics tool for transport or a small crew when protocol includes it. It is not a quality upgrade by default.
• Head-up CPR, with the head and chest raised during compressions, is discouraged outside a formal research trial. Do not raise the head as a routine way to improve CPR.
• AHA 2025 says to start with an IV in adult arrest. Use IO if the IV fails or is delayed. Use the same dose you would give by IV, then flush. Protocol owns the site. Do not pause compressions for a perfect line.

Where CPR quality fails

• Long pauses around the shock. See shockable arrest.
• Watching fine VF instead of compressing. See asystole vs fine VF.
• Bagging faster than 20 breaths a minute because the patient looks lifeless. Too much ventilation raises pressure in the chest and drops blood returning to the heart.
• Leaving one person on compressions for the whole resuscitation.

Pediatric differences

Pediatric CPR still uses 100 to 120 compressions a minute and full recoil. Ventilation is different. With an advanced airway, children get 20 to 30 breaths a minute, not the adult rate of about 10. For infants, use one hand or the two-thumb encircling method. Do not use two fingers. See pediatric airway.

Common errors

• Compressing on a mattress without a backboard or the floor under the patient.
• Placing the hands too high, on the neck, or too low, on the xiphoid or abdomen.
• Calling CPR good without watching depth and recoil.

Practice

Related: Shockable Arrest, ROSC, Waveform Capnography.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
• AHA 2025 Part 7: Adult Basic Life Support
• AHA 2025 Part 9: Adult Advanced Life Support
• Rate 100–120, depth at least 5 cm (2 in), full recoil, short pauses, 30:2 until an adult advanced airway, then about 10 breaths/min with continuous compressions. Work where you found them if CPR is safe and effective. Mechanical CPR is not routine. Head-up CPR is not routine care. Start with IV in adult arrest. Use IO if the IV fails or is delayed. Use the same dose, then flush.