2019 HPCPR Inst Guide MH

High Performance CPR
Instructor Guide
Seattle/King County Resuscitation Academy

February 1, 2019
©2019 All Rights Reserved

Module 1: Science of HP-CPR
Segment Time: 25:00 Minutes
Overview
An important element of resuscitation care is HP-CPR and evidence indicates that the highest quality of CPR
compressions combined with minimal interruptions to CPR has a significant effect on patient outcomes. Learning
the science that drives the key areas of emphasis including depth, rate, recoil, minimizing interruptions and
controlled ventilations helps students to better understand “The Big Picture” of HP-CPR.
Objectives
 Understand the science behind High-Performance CPR (HP-CPR).
 Recognize the importance of the essential elements of HP-CPR: proper compressions (depth, rate,
recoil), controlled ventilations, high compression fractions and minimizing interruptions.
Presentation Materials
Science of CPR video segment
Instructor Activities
Introduce Science of HP-CPR
Show video
Emphasize Key Points
Answer questions
Practice
No practice for this segment
Key Points
1. This training will focus on the science and integration of the elements of HP-CPR into the
resuscitation response.
2. HP-CPR includes quality chest compressions (rate, recoil and depth), controlled ventilations, high
compression fractions and minimizing pauses. The science of HP-CPR creates understanding why these
elements are so important and the impact that each has on cardiac arrest outcome.
Module 2: Overview to HP-CPR
Overview
Successful resuscitation requires a coordinated approach and expertly-performed CPR. This course will focus on the
important elements and share an overview of High-Performance CPR, as part of a total resuscitation response.
Objectives
 Understand the integration of BLS and ALS care when multiple rescuers respond to cardiac arrest.
 Recognize the importance of a coordinated approach to resuscitation care.
HP-CPR Video Scenario BLS and ALS - integrated cardiac approach
Introduce HP-CPR
Show video
Emphasize Key Points
Answer questions
Practice
No practice for this Segment
Key Points
1. HP-CPR includes high-quality chest compressions (rate, recoil and depth), controlled ventilations,
high compression fractions and minimizing pauses combined with close coordination and
communication during resuscitation activities. Programmatically, it will be YOUR responsibility to
identify, design and incorporate these HP-CPR principles to best fit your departmental needs as it
pertains to a cardiac arrest response.
2. Important to recognize that HP-CPR is more than CPR, it also includes the important elements of
team communication and coordination.
3. In HP-CPR, everyone has a pre-defined role at the start of the resuscitation to ensure that all essential
tasks are being accomplished as quickly and efficiently as possible. This is the same model used to
attack fires and by racing pit crews.
Module 3: BLS CPR
Overview
The CPR provided by BLS responders is an important part of resuscitation response. During resuscitation, the BLS
provider (initial responder) owns the CPR portion and should assure that interruptions are minimized. It is often
necessary for the BLS provider to assume the lead role in the resuscitation to assure that the resuscitation team,
including ALS responders, maintain focus on continuous, expertly-performed CPR. We will break HP-CPR into the
individual components of initial assessment, compressions, ventilations and combining compressions and
ventilations. Practice sessions will occur for each of the components.
Objectives
 Understand the role of the BLS (initial) provider in providing resuscitation care.
 Identify the key aspects of HP-CPR.
 Understand the roles of each member of the resuscitation team.
Optional – If response model includes only two or three responders, show Two or Three Rescuer CPR video segment.
Introduce BLS HP-CPR
Show video if
necessary
Emphasize Key Points as needed
Answer questions
Practice
No practice for this Segment
Key Points
1. BLS owns the CPR portion of the resuscitation
2. Initial assessment: combine arousal, check for breathing and check for pulse into single action
taking less than 10 seconds.
3. Avoid interruptions to chest compressions.
4. Proper compression depth (2-2.4”), rate (110 to 120 CPM). Use of a metronome is HIGHLY recommended
5. Full (complete) chest recoil with equal compression/decompression cycle
6. Rotate compressors every 2 minutes.
7. Hover hands (over chest) prior to and during analysis. Additionally, hover finger over shock button.
8. ALS skills performed around HP-CPR
Module 4: Initial Assessment
Overview
Initial assessment; checking for responsiveness, breathing and pulse is traditionally performed as a three-step
process with each step taking several seconds. It would not be uncommon for a rescuer to take 30 seconds or more
to complete an initial assessment. By performing all three steps simultaneously, an initial assessment can be
completed in less than 10 seconds, reducing the time it takes to begin chest compressions.
Objectives
 Recognize the importance of minimizing the time required to complete an initial assessment.
 Practice performing initial assessment in less 10 seconds or less.
Show initial assessment video segment.
Introduce initial assessment
Show video segment
Conduct practice session
Answer questions
Practice
Organize students in groups of 2-3 while using a manikin to perform the task
Have students perform initial assessment, checking responsiveness, breathing and pulse simultaneously with
a goal of completing the assessment in less than 10 seconds.
Key Points
1. One rescuer should be assigned the job of initial assessment prior to arrival at the patient.
2. Initial assessment should be completed in less than 10 seconds.
3. A second rescuer should get into position (bare patient’s chest and hover) to begin
compressions while initial assessment is being completed.
Module 5: Chest Compressions
Overview
Chest compressions of adequate depth, rate and recoil are perhaps the most critical elements of HP-CPR. Recent
science indicates that compressions must be between 2-2.4 inches for an adult, the rate should be 100 to 120
compressions per minute and that the compression and decompression cycle (duty cycle) should be equal with full
and COMPLETE recoil.
Objectives
 Recognize the importance of chest compressions as an element of HP-CPR.
 Understand why body positioning, depth, rate and recoil of compressions and a proper duty
cycle are critical to quality compressions.
 Practice performing chest compressions.
Show chest compressions video
NOTE: Use SINGLE metronome
over house audio system
Introduce Chest Compressions
Show video segment
Answer questions
Practice
Organize students in groups of 2-3.
Have students perform two minute cycles of chest compressions on an instrumented manikin. Show feedback!
Have peers provide coaching for depth, rate, recoil and duty cycle compliance. Use a metronome to provide
rate.
Key Points
1. Hands need to be placed in the center of the chest.
2. Depth of compression at 2-2.4 inches.
3. Body mechanics are very important for providing high-quality compressions: Correct distance from
patient’s side, arms locked at elbows, perpendicular to patient’s sternum, torso and arms performs
compression as a unit and fulcrum at waist.
4. Emphasis on smooth motion with equal compression and decompression cycle (duty cycle). Full recoil is
REQUIRED for refilling the coronary arteries.
5. Rate 100-120 compressions per minute. (use metronome over the house audio system to limit confusion)
Module 6: Ventilations
Overview
Ventilations have a reduced priority in HP-CPR. Over-ventilation and hyperventilation is common when provided by
professional responders and is detrimental to CPR quality and survival from cardiac arrest. Rescuers should focus on
when it is appropriate to add (controlled) ventilations and limiting ventilation volume and rate.
Objectives
 Understand the importance of “controlled” ventilations (volume and rate).
 Recognize how over-ventilation can be detrimental to quality CPR.
 Practice performing “controlled” ventilations.
Show ventilations video
Introduce Ventilations
Show video segment
Show “C3” technique
Demonstrate three finger bag squeeze
Demonstrate end of bag squeeze
Answer questions
Practice
Organize students in groups of 2.
Perform one minute of controlled ventilations on an instrumented manikin, then switch.
Have peers provide coaching for seal, volume and
rate.
Show feedback
Key Points
1. Use the “C3” technique of creating seal with the BVM.
2. Breaths no more than one second duration.
3. Limit volume to 350 - 500 ml. A three finger (pinky out) squeeze helps limit volume.
4. Slight chest rise is a good indicator of volume and seal.
5. If using a two-person technique, pull face (up) into the mask rather than pushing down on face.
Module 7: Ventilations and Compressions
Overview
Teamwork is an important aspect of providing resuscitative care. To be effective, the BLS CPR Team must assure the
efficient coordination of ventilations and compressions. This includes rotating positions, especially the compressor,
every two minutes.
Objectives
 Recognize the importance of teamwork during HP-CPR.
 Understand the importance of coordination of compressions and ventilations.
 Practice performing coordinated compressions and ventilations.
30:2 and 10:1 (continuous) videos
Introduce Compressions and Ventilations
Show video segments
Answer questions
Practice
Have students perform two-minute cycles of chest compressions with ventilations on a manikin.
Have peers provide coaching to compressor for depth, rate, recoil and duty cycle compliance.
Have peers provide coaching to ventilator for controlled ventilations, (seal, volume and rate).
Start out practicing 30:2 and then have teams switch to 10:1 continuous.
Show feedback
Key Points
1. Compressions should not be interrupted for ventilations more than needed to deliver breath(s).
2. Compressor counts out loud to signal ventilation.
3. Compressor takes charge of the “pause” during ventilations (30:2)
4. A countdown to the end of the two-minute CPR interval helps to prepare for switching compressors.
5. The switching of compressors should be accomplished in less than 5 seconds. This is accomplished
by anticipating the end of the CPR cycle and counting down the last 15 seconds.
6. Re-emphasize key points from compressions and controlled ventilations as needed.
Module 8: Defib Familiarization
Overview
HP-CPR and defibrillation are known to be the most effective treatment for a victim of cardiac arrest. However, an
AED can also cause significant gaps in CPR during analysis and shock. Understanding the operation and limitations
of your AED and how to minimize interruptions caused by the devices, will increase the percentage of time
compressions are provided during resuscitation.
Objectives
 Recognize the operational capabilities and limitations of the AED used by your organization.
 Identify techniques that can be used to minimize the time compressions are interrupted by the AED.
 Practice applying and operating the AED used by your organization.
 Other team members should practice countdown, hovering and rotation while the AED is being operated.
AED Use, Shock/No Shock Advised, Pre-Charge videos
Introduce AED Integration (Show video segments as appropriate)
Demonstrate operation and limitations of AED in use
Demonstrate “pre-charging” manual defibrillators at 15 seconds prior to analysis/pause (1:45)
Answer questions
Practice
Have students practice applying and delivering shocks with an AED/AED Trainer on a manikin.
Key Points
1. It is important to understand the operation and limitations of the device used by your organization.
2. Voice prompts and charging can cause significant delays in chest compressions.
3. Anticipating the AED’s actions and providing solutions limitations will reduce interruptions to CPR.
a. Pre-charging manual defibrillators at 15 seconds prior to analysis/pause (1:45)
b. Pre-clearing for shock, includes timer countdown, (10 seconds)
c. Hands hover above chest during analysis and shock, IMMEDIATE return to compressions post shock.
d. Hover finger over shock button
e. Femoral pulse check during analysis
f. No pulse check after shock.
g. Crew rotation takes place during analysis and charging of AED
Module 9: Communication and Coordination
Overview
Successful resuscitation requires the coordinated efforts of the response team. In the best response to cardiac arrest,
each responder understands their role and the importance of communication and coordination during the delivery
of care.
Objectives
 Recognize the importance of communication and coordination as an element of HP-CPR
 Understand the different roles within the response team
 Discuss how team size and certification level have an effect on team roles
Team Rotation Video
Introduce Communication and Coordination
Show Video Segment
Discuss Team Roles
Answer questions
Practice
No practice for this segment
Key Points
1. Good communication and coordination are essential elements of HP-CPR
2. Uncoordinated/inefficient movements increase CPR pause time (and reducing compression fraction)
3. Understanding all roles within the responder group is important as each member will likely rotate
through several if not all roles.
4. Team roles include: Compressor, Ventilator, AED/Monitor Operator, Time keeper and “On Deck”.
One team member may have to fill more than one role
5. The switching of compressors should be accomplished in less than 5 seconds. This is accomplished
by anticipating the end of the compression cycle and counting down the last 15 seconds. Release
the ventilator 5-10 seconds early to prepare for the rotation (if indicated)
Module 10: HP-CPR Scenarios
Overview
Practicing scenarios helps to increase understanding of and competency with HP-CPR techniques.
Objectives
 Review the techniques of HP-CPR that help minimize interruptions to CPR.
 Practice cardiac arrest scenarios using HP-CPR techniques.
Optional – show BLS CPR Video again
Introduce Scenarios
Show BLS CPR video (optional)
Answer questions
Practice
Have students practice several different cardiac arrest scenarios, ensuring that each student rotates through
all five possible roles – Compressor, Ventilator, AED/Monitor Operator, Time keeper and “On Deck”.
Practice should include all of the HP-CPR elements:
 Integrated Initial Assessment (no more than 10 seconds)
 CAB Approach
 Compressions with adequate depth, recoil and rate. Good body mechanics.
 Controlled ventilations no more than one second long and 350-500mls delivered with three fingers
 Anticipate next actions with countdowns and hands hovering over chest and AED. No pulse check
after shock.
 Quick transitions between roles. Rotate during AED analysis.
Ensure that peers continue to provide coaching as needed to improve technique.
Key Points
1. It is important for each team member to understand their initial and next role.
2. Rotation through all roles is important to understand each team member’s responsibilities.
3. Emphasize the importance of anticipating next actions and not waiting for AED prompting after
analysis, shock or no shock advised.
- Optional
Module 11: Integration of ALS

Overview
The arrival of ALS personnel during BLS HP-CPR needs to be integrated and choreographed. In addition, ALS skills
such as the initiation of an IV/IO, airway management and rhythm analysis often cause interruptions to chest
compressions. It is important that the BLS crew continue to own the CPR portion of the resuscitative efforts and that
ALS providers be proficient in providing skills with continuous CPR while minimizing unnecessary interruptions to
chest compressions.
Objectives
 Recognize the impact of ALS arrival during HP-CPR.
 Identify methods for providing ALS skills while compressions are in progress.
 Practice BLS/ALS Teamwork while performing HP-CPR scenarios.
Integrating ALS Video
Introduce ALS Integration Show video or have local rescuers provide live demonstration
Facilitate demonstration
Conduct group scenarios (Optional)
Answer questions
Practice
Have students practice scenarios that integrate ALS care on a manikin.
If time is limited, have one group of BLS and ALS participants perform scenario to demonstrate to remaining
participants.
Key Points
1. When ALS providers arrive, they should begin setup and switch over to their monitor during a two-
minute CPR interval.
2. Initiation of an IV and advanced airway management should begin without interrupting
compressions.
3. Pre-charge the defibrillator during the last 15 seconds of the CPR interval. (1:45)
4. BLS leader remains in charge of CPR and tracking of intervals.
- Optional
Module 12: Mechanical CPR

Segment Time: 15:00
Minutes
Overview
Mechanical CPR devices can be a useful adjunct for providing CPR during a resuscitation. These devices can provide
compressions for resource limited crews or increase safety for rescuers during transport. However, evidence
suggests that compressions provided by humans still result in better outcomes. Each organization should evaluate
the use of mechanical CPR devices and how these devices can be integrated into resuscitation operations.
Objectives
 Recognize how mechanical CPR devices can be used for resuscitation.
 Understand limitations of mechanical CPR devices.
 Review methods of applying mechanical CPR devices with minimal interruptions.
 Practice application of a mechanical CPR device during resuscitation scenarios.
 Limit application time to <10 seconds
Mechanical CPR Video
Introduce Mechanical CPR
Show video
Facilitate demonstration
Conduct group scenarios (Optional)
Answer questions
Practice
Have students practice applying a mechanical CPR device on a manikin.
Key Points
1. Mechanical CPR devices have a role in providing compressions during resuscitations. However,
these devices have not been shown to be a more effective replacement for human CPR.
2. These devices have limitations for patient size.
3. Studies show that some mechanical CPR devices result in higher injury rates than human CPR.
4. Limit application time to <10 seconds

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High Performance CPR

Seattle/King County Resuscitation Academy

©2019 All Rights Reserved

Module 11: Integration of ALS

Module 12: Mechanical CPR

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