Optimize Chest Compressions

Chest Compressions Basics


On occasion, I get the honor of being to “asked” to help with my daughter’s homework. It isn’t common, fortunately, as I don’t recall middle school algebra that well, but recently I was emphasizing the fact that you cannot expect excellent results from complicated systems (equations) if you fail to do the basics correctly.

Often we get distracted with “advanced” strategies and techniques. While advanced procedures can be effective, suboptimal performance of the basics will undermine the entire project.  This concept, I think, is easily reflected when we are involved in resuscitations.  Focusing on the choice between lidocaine, procainamide, and amiodarone is fruitless if the team is not performing the basics optimally.  Without question, The Basics are the Best! (These are important to know for everyone… including parents!)

We all know that the American Heart Association has emphasized the focus on the basics, and we recently discussed the need to de-emphasize pulse checks, but let us now look at how to optimize our chest compressions!


What are Quality Chest Compressions

  • For pediatrics patients quality chest compressions require:
    • Rate of 100 compressions per min
    • Compression Depth of 1/3 AP diameter
    • Compressions that allow for complete recoil of the chest!
      • This is just as vital as the depth and the rate, but often under appreciated!
      • It is during recoil phase that the heart chambers fill with blood and the coronary arteries have blood flow.


Quality Chest Compressions Matter

  • Goal of delivering CPR is Return of Spontaneous Circulation (ROSC) and Maintaining Cerebral Perfusion.
    • Obvious ROSC is important, but survival with good neurologic outcome is the real goal.
  • Quality chest compressions can generate good MAP.
    • This is integral to having a chance to provide cerebral perfusion!
    • Sutton et al. showed that quality chest compressions can generate systolic BP >80 and diastolic BP >30!
  • Quality chest compressions can lead to improved survival.
    • When compared to suboptimal chest compressions, quality chest compressions have been associated with improved survival in the first 24 hours.
    • Obviously, this does mean overall survival, but you have to start somewhere.


Optimize Chest Compressions

  • Since chest compressions are so important, one of the most important roles a team leader has is to ensure they are being optimized.
    • Use a BackBoard!
      • Even with adults this is important, but particularly true in children.
      • Often the compression of the gurney’s mattress will significantly diminish the actual AP compression of the patient!
      • The backboard can be easily overlooked and if not present, all of the efforts are being undermined!!
    • Get the timing down! Use a Metronome!
      • Often it is recommended to do compressions to the beat of a song…
        • But even if we all sing the same song, the tempo of that song can easily be misjudged.
      • Take the guess work out of it… is an automatic timing system.
        • Use a metronome to help define what 100/min is.
        • There is “an app for that.”  Some apps will use your smartphone’s flash to signal that rate… which give nice visual cues to the compressor.
        • There are also “fancy” commercial products available that can give cues to the timing and depth of compressions, but they aren’t free.
    • Use End-Tidal CO2 to provide feedback.
      • Studies show that EtCO2 can be a surrogate maker of blood flow produced during compressions in both adult and pediatric patients.
        • CPR is a low flow state, and as such, EtCO2 becomes less dependent upon CO2 production and ventilation and is more related to Cardiac Output.
        • Since pediatric arrests are usually due to respiratory (or infectious) etiology, do not rely on the initial EtCO2 value.
        • The value is more reliable after 1 min of compressions.
      • Goal EtCO2 of between 10-15 during chest compressions.
        • Can be used as a feedback device… as it indicates quality compressions are being done.
        • If EtCO2 <10, ROSC is unlikely. Double check your quality characteristics!
      • If EtCO2 increases substantially during chest compressions, this likely indicates ROSC.
        • Using this method can help decrease interruptions in chest compressions for “pulse checks.”
        • Just seeing an increase would not lead me to stopping compressions… I’d likely complete that 2 min cycle before checking for pulse.
    • Mandate the Rotate!
      • While we work with many true heroes, this is not a time to allow someone’s self-sacrifice to interfere with quality chest compressions.
        • Even the strongest and biggest person will get tired.
        • The power to do quality chest compressions is similar to that of running or swimming.
        • While the compressor may be a physically fit individual, he/she will not sprint at the same rate the entire time.
      • Studies show there is a measurable and significant decrement in quality of chest compressions at 2 minutes for both adult and pediatric patients!
        • Interestingly, the rate and depth often stays the same, but the compressor begins to lean on the chest.
        • This decreases the chest recoil!!  We cannot have that.
      • Do not ask if the compressor is “ok.”
        • Tell him or her that it is time to rotate rapidly and have the next person prepped and ready to take over without interruption!
        • Even if it is Superman, tell him it is time to rotate for the sake of optimizing your chest compressions!


Hamrick JL1, Hamrick JT, Lee JK, Lee BH, Koehler RC, Shaffner DH. Efficacy of chest compressions directed by end-tidal CO2 feedback in a pediatric resuscitation model of basic life support. J Am Heart Assoc. 2014 Apr 14;3(2):e000450. PMID: 24732917. [PubMed] [Read by QxMD]

Sutton RM1, French B2, Niles DE3, Donoghue A3, Topjian AA3, Nishisaki A3, Leffelman J3, Wolfe H3, Berg RA3, Nadkarni VM3, Meaney PA3. 2010 American Heart Association recommended compression depths during pediatric in-hospital resuscitations are associated with survival. Resuscitation. 2014 Sep;85(9):1179-84. PMID: 24842846. [PubMed] [Read by QxMD]

Badaki-Makun O1, Nadel F, Donoghue A, McBride M, Niles D, Seacrist T, Maltese M, Zhang X, Paridon S, Nadkarni VM. Chest compression quality over time in pediatric resuscitations. Pediatrics. 2013 Mar;131(3):e797-804. PMID: 23439892. [PubMed] [Read by QxMD]

Sutton RM1, French B, Nishisaki A, Niles DE, Maltese MR, Boyle L, Stavland M, Eilevstjønn J, Arbogast KB, Berg RA, Nadkarni VM. American Heart Association cardiopulmonary resuscitation quality targets are associated with improved arterial blood pressure during pediatric cardiac arrest. Resuscitation. 2013 Feb;84(2):168-72. PMID: 22960227. [PubMed] [Read by QxMD]

Tress EE1, Kochanek PM, Saladino RA, Manole MD. Cardiac arrest in children. J Emerg Trauma Shock. 2010 Jul;3(3):267-72. PMID: 20930971. [PubMed] [Read by QxMD]

Kleinman ME, de Caen AR, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D; Pediatric Basic and Advanced Life Support Chapter Collaborators. Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010 Oct 19;122(16 Suppl 2):S466-515. PMID: 20956258. [PubMed] [Read by QxMD]
Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

Articles: 583


  1. Doc, I LOVE your columns…. and routinely go back and read old ones!
    I run a Face Book page of neonatal case studies for the American Academy of Neonatal Nursing…
    I also routinely lecture on etCO2 (as well as neo-pedi topics both in the US and in Haiti)….
    I am also AHA National faculty in BLS, ACLS and PALS (and an NRP instructor)
    I have found it of value to explain the DIRECT correlation between etCO2, pulmonary perfusion…
    in the absence of shunt pathophysiology, an etCO2 of 10- 15 equates to a CO of > 1 LPM…. > 25% of low-normal,
    which is minimum goal of cerebral perfusion directed resuscitation.
    not only can you use etCO2 to guide pacing and inotropic gtts, if you are NOT achieving etCO2s of 10-15, but ARE doing “picture perfect” CPR, that MAY be evidence of a V/Q mismatch over and above poor pulmonary perfusion secondary to poor CPR…
    such as a PE or a tension pneumo, the latter which can occur during resuscitation, secondary to PPV…..

    just my 2 cents on my personal teaching points…. again… LOVE YOUR STUFF!!!!

    Warm Regards and Very Much Looking Forward to Your Next,
    Sean G. Smith
    BSN, RN, Paramedic

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