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So let’s talk about one of the most important concepts in resuscitation — it’s something called chest compression fraction, otherwise known as CCF. What is CCF exactly? It's the percentage of time during a cardiac arrest that chest compressions are actually happening. And here’s what really matters: the more time you spend compressing the chest properly, the better the patient’s chances of survival. So what causes low CCF anyway? Well, interruptions in compressions — particularly during rhythm analysis and defibrillation. When we’re providing ventilations, we have time requirements for giving those effective breaths if we don’t have an advanced airway in place. And that is one second per breath and then two seconds between those. It’s important to make sure that breaths are effective but we must minimize the delay in the chest compressions. And though an advanced airway is best practice in an arrest for protecting the airway, inserting an advanced airway may not always be an option, so we look for other places that we can increase the time with compressions being applied to the chest. So the other action we perform that may affect the CCF is rhythm checks. But how can we possibly check a rhythm without delaying cardiac compressions? The goal is to complete rhythm analysis and deliver a shock — if needed — in under get this, 10 seconds or less. In order to do this well, the whole team needs to anticipate what's coming next, and stay coordinated, and execute specific strategies before, during, and after the pulse check. So let’s take a closer look at how this can be accomplished. The following is the latest ECC Guidelines for working in concert with a resuscitation or CODE team. Step 1: Precharge the Defibrillator. See, precharging the defibrillator is one of those simple habits that makes a huge difference. It eliminates the delays and keeps your pauses in compressions as brief as possible. One example of how this can be accomplished is 15 seconds before you hit the 2-minute mark on CPR compressions, have the team member in charge of the defibrillator set its proper joule setting and then precharge. If ventricular fibrillation or pulseless ventricular tachycardia is identified during the rhythm analysis, one can deliver the shock immediately — thereby saving tons of time. Precharging is one of those simple habits that makes a big difference. It eliminates delays and keeps pauses in compressions to a minimum. As a safety note, however: before implementing this strategy into your high-performance team, be familiar with your heart monitor/defibrillator in order to know how to disarm or “dump” an unneeded charge. Now let’s cover pulse check timing. It’s important to pick one person and keep them there for the entire code whenever possible. Consistency wins in this case. Same provider, same position, same technique—this reduces hesitation and wasted movement when it’s time to check for a pulse. Fewer variables means faster, cleaner pauses. Secondly, we’re going to locate the femoral site before the pause. Don’t wait until compressions stop to start searching for the femoral artery. While compressions are ongoing, place two fingers in the groin crease—just below the ligament, about halfway between the hip bone and the pubic area. Use your fingertips, never your thumb, of course; it has its own pulse. You’re not deciding anything yet—you’re just finding your spot so you’re ready to go. If allowed, consider maybe even marking the pulse location with an accurate medical marker. Hold the location without losing it. Once you’ve found the artery, stay there. Light contact is key—enough to keep your place, not so much that you collapse the vessel. Think of it like we're setting our own visual marker if indeed we’re not using a real mark with ink. You’ll confirm during the pause, but you don’t want to search for that location every single time we go through that cycle. We’re going to set the team before the check; everybody’s in their place. As you approach the end of the compression cycle, the leader should cue the team. And everyone should be ready—the compressor finishing strong, monitor is visible, the defib charged if needed, the pulse checker is already in position. During this pause cycle, make a clear decision. As soon as compressions stop, apply slight pressure and answer one very important question: is there a clear, definite pulse? No guessing here. No adjusting over and over; this is a time waste. And if it’s not obvious, treat it as though it’s absent. Look at the whole picture, not just your fingers. Don’t rely just on touch alone; they can error, and they often do. It’s a very unsettled situation. Check the monitor, watch for patient movement, pay attention to capnography trends. If there’s a sudden rise in the ETCO₂, monitor an organized rhythm can support what you’re feeling—but none of it replaces a quick, decisive assessment. If we don’t feel it, get back to compressions. We’ve got 10 seconds or less, and if a pulse isn’t clearly there, it just isn’t there. Compressions are going to restart immediately. After the shock, go straight back to compressions, no hesitations. Deliver the shock and get right back on the chest compressions. We’re not gonna pause to check a pulse. Every unnecessary delay costs perfusion and pulse pressures. Let's not force the femoral site if it’s not working. Sometimes this is a bad location to check for a pulse. It can be difficult to access due to many things, including the physique of the patient, positioning, or other environmental problems. If we can’t get a reliable answer quickly, then switch to a site we can assess better. The goal is to speed up the accuracy of our treatment. Lastly, let’s use better tools when they’re available. If capnography and an arterial line is available, along with maybe ultrasound, then let's use them—they can give us much more accurate and reliable information. But not at the expense of extending and wasting time. The priority never changes: keep compressions going and keep interruptions minimal. Our patients' survival and their out-of-hospital discharge quality may definitely depend on it. Now let’s cover the compressor positioning during pauses. Now, this next topic it might actually sound simple, but don’t let it fool you, it's actually very important! — What your compressor does during a compression pause can matter more than we realize. When compressions pause for any reason, the compressor should maintain their position, hovering over the chest in the right location. So what does hovering actually mean? Well, it means staying in position — the hands will be just a few inches above the chest, but over the appropriate area on the chest, not touching the chest — but ready to begin the compressions the moment they receive the signal. And as we approach the 2-minute mark, the next compressor should already be in position and ready to switch the moment the team calls for a rhythm check. Hovering serves really two important purposes: it doesn't interfere with the rhythm analysis, and it allows compressions to resume immediately — whether that's after a rhythm check, following the delivery of a shock, or after any other necessary pause. Now let’s cover advanced airways. Let's talk a little bit about airway management. The guidelines and best practices now state that we should start with a basic airway unless there's a clear and immediate reason to lead with an advanced airway. Whether we’re using basic or advanced, their placing of the capnography or capnometry while using a bag-valve mask is still the best practice. The priorities of high-performance CPR are in this order: high-quality in compressions first, then monitoring, then defibrillation, then IV access followed by medications. Once those steps are initiated, advanced airways like intubation or supraglottic devices can be considered. If defibrillation is initially delayed, be sure ventilations are performed after the first 30 compressions whenever possible. Let’s keep in mind that guidelines state that when placing an advanced airway, compressions should not stop. Once the advanced airway is in place, switch to continuous compressions with asynchronous ventilations — one breath every six seconds. When intubated, the 30:2 ratio is no longer used. Studies have actually shown that continuous compressions alone increase CCF by over 10%. That's a significant impact just from changing how we manage the airway. Let's take a closer look at the topic of medication delivery. See guidelines state to administer medications right after rhythm checks. The reason this method works so well is that it naturally aligns with the algorithm and keeps medication timing on track. Here’s how the sequence may look: compressions resume immediately after the rhythm check, the team identifies the correct medication, medications are administered. And then following this process, this helps ensure that the medications are delivered approximately every two minutes, or as needed, minimizing time wasted and helping with accuracy and efficiency. Next, we’re going to discuss facility implementation of the high-performance CPR. In reality, these strategies we’ve discussed are only as effective as the team is in executing them. Consistent training, good communication, clear roles and responsibilities, and regular practice are what truly makes the difference during a real cardiac arrest. Everyone on the team must own their role, stay one step ahead, and communicate with purpose and precision. Set the standards early—you know, define those expectations clearly, including any facility-specific protocols that guide your response, before the cardiac arrest happens. See, when everyone understands their job and the objective, the entire resuscitation attempt improves and in the end, may in turn lead to another life saved. Maximizing chest compression fraction has been proven to improve cardiac arrest survival and better quality of life after discharge. Improving the CCF is one way that we can effectively make a difference, but we’ve gotta work as a high-performance team to do it. Remembering ways to act as a high performance resuscitation team includes: precharging early because delays lead to decreased survival hopes, combine your pulse check with rhythm analysis to save time, always stay in the ready position as a compressor— hover and be prepared to resume compressions immediately without delay, no pause in compressions for airway placement or medication delivery, and most importantly — train and work as a team, so everyone is on the same page working as a high performance and effective resuscitation team. High-performance CPR isn't just about what only one person can do. It's about precision, timing, and teamwork. When the whole team is working together with these strategies in place, you will give the patient a significantly better chance of survival. And doesn’t the patient and their loved ones deserve that?
In this lesson, we'll cover one of the most important concepts in resuscitation—something called chest compression fraction, otherwise known as CCF.
What is CCF exactly? It's the percentage of time during a cardiac arrest that chest compressions are actually happening. And here’s what really matters: the more time you spend compressing the chest properly, the better the patient’s chances of survival.
So what causes low CCF anyway? Interruptions in compressions—particularly during rhythm analysis and defibrillation.
When we’re providing ventilations, we have specific time requirements for giving those effective breaths if we don’t have an advanced airway in place. That is one second per breath, and then two seconds between those. It’s important to make sure that breaths are effective, but we must minimize the delay in chest compressions. Although an advanced airway is best practice in an arrest for protecting the airway, inserting one may not always be an option, so we look for other places that we can increase the time with compressions being applied to the chest.
The other action we perform that may affect the CCF is rhythm checks. But how can we possibly check a rhythm without delaying cardiac compressions? The goal is to complete rhythm analysis and deliver a shock—if needed—in 10 seconds or less. In order to do this well, the whole team needs to anticipate what's coming next, stay coordinated, and execute specific strategies before, during, and after the pulse check.
The following is a breakdown of the latest ECC Guidelines for working in concert with a resuscitation or CODE team.
Precharging the defibrillator is one of those simple habits that makes a huge difference. It eliminates delays and keeps your pauses in compressions as brief as possible.
One example of how this can be accomplished is 15 seconds before you hit the 2-minute mark on CPR compressions, have the team member in charge of the defibrillator set its proper joule setting and then precharge. If ventricular fibrillation or pulseless ventricular tachycardia is identified during the rhythm analysis, you can deliver the shock immediately—thereby saving tons of time.
Pro Tip #1: Precharging eliminates unnecessary lag, keeping pauses in compressions to an absolute minimum. As a safety note, however: before implementing this strategy into your high-performance team, be thoroughly familiar with your heart monitor/defibrillator in order to know exactly how to disarm or “dump” an unneeded charge.
To optimize your pulse check routine and keep your CCF high, focus on these critical coordination strategies:
Pro Tip #2: During the pause cycle, make a clear and fast decision. As soon as compressions stop, apply slight pressure and answer one vital question: is there a clear, definite pulse? There is no room for guessing or adjusting over and over, as this wastes valuable time. If a pulse is not obvious, treat it as though it’s absent.
Look at the whole picture, not just your fingers. Don’t rely on touch alone, as tactile feel can easily error in high-stress situations. Check the monitor, watch for patient movement, and pay close attention to capnography trends. A sudden rise in the ETCO2 on a monitor displaying an organized rhythm can support what you’re feeling—but none of it replaces a quick, decisive assessment. If you don't feel a pulse, get right back to compressions. We’ve got 10 seconds or less, and if a pulse isn’t clearly there, it just isn’t there.
Compressions are going to restart immediately. After a shock is delivered, go straight back to compressions with no hesitations. Never pause to check a pulse immediately following a shock; every unnecessary delay costs perfusion and pulse pressures.
Additionally, do not force the femoral site if it’s not working. Sometimes it can be a difficult location to access due to the physique of the patient, positioning, or environmental issues. If you can’t get a reliable answer quickly, switch to a site you can assess better. Finally, use better tools when they are available. If capnography, an arterial line, or ultrasound are available, utilize them—they provide highly accurate and reliable information. However, this should never come at the expense of extending or wasting time. The priority never changes: keep compressions going and keep interruptions minimal.
What your compressor does during a compression pause matters more than we realize. When compressions pause for any reason, the compressor should maintain their position, hovering directly over the chest in the right location.
Pro Tip #3: Hovering means staying perfectly in position—keeping your hands just a few inches above the chest over the appropriate area without actually touching it. This keeps you ready to begin compressions the moment you receive the signal. As you approach the 2-minute mark, the next compressor should already be in position and ready to switch the moment the team calls for a rhythm check.
Hovering serves two critical purposes: it doesn't interfere with the rhythm analysis, and it allows compressions to resume immediately—whether that's after a rhythm check, following the delivery of a shock, or after any other necessary pause.
Current guidelines and best practices state that we should start with a basic airway unless there's a clear and immediate reason to lead with an advanced airway. Whether you're using basic or advanced options, placing capnography or capnometry while using a bag-valve mask remains best practice.
The priorities of high-performance CPR must follow this specific order:
Once those steps are initiated, advanced airways like intubation or supraglottic devices can be considered. If defibrillation is initially delayed, be sure ventilations are performed after the first 30 compressions whenever possible.
Keep in mind that guidelines explicitly state compressions should not stop while placing an advanced airway. Once an advanced airway (such as an LMA, laryngeal tube, or i-gel) is in place, switch to continuous compressions with asynchronous ventilations at a rate of one breath every six seconds. When the patient is intubated, the 30:2 ratio is no longer used. Studies have shown that continuous compressions alone increase your CCF by over 10 percent.
For medication delivery, guidelines state to administer medications right after rhythm checks. This method naturally aligns with the algorithm and keeps medication timing perfectly on track. The sequence flows smoothly: compressions resume immediately after the rhythm check, the team identifies the correct medication, and the medications are administered. Following this process ensures that medications are delivered approximately every two minutes, or as needed, minimizing wasted time while maximizing accuracy and efficiency.