High Performance CPR is the newest phrase to come out the world of resuscitation, but what does it mean?

High performance CPR is a new name for an older idea, the “Pit Crew Concept” or “Pit Crew CPR” which was developed by the United Kingdom’s National Health Service (NHS) and inspired by Formula One racing.

When a race car driver pulls into the pit for service, everyone that comes over the wall in the pits has a job, and they cannot delay in beginning that job as seconds gained or lost on a pit stop can determine the outcome of a race. CPR applies the same concept to the resuscitation of patients suffering from Sudden Cardiac Arrest (SCA). Resuscitation must begin as quickly as possible. Everyone must know their job and begin the assigned task immediately to increase the likelihood of a successful resuscitation. Just like in the auto racing pits, seconds matter.

High Performance CPR and Pit Crew CPR

The pit crew concept requires responders to initiate chest compressions as soon as they identify a patient in cardiac arrest.

A minimum of three healthcare providers need to be by the patient’s side to perform pit crew CPR as it is intended — one on the patient’s right side, another on the left side and the third at the patient’s head managing the airway.

The rescuers that positioned themselves to the right and left of the patient are responsible for chest compressions. The provider on the right will provide high-quality chest compressions for 2 minutes while the provider on the left applies the automatic external defibrillator (AED) or cardiac monitor defibrillation pads. After 2 minutes, the provider on the left will take over chest compressions for 2 minutes, then the rescuers will alternate back and forth. Between sets of compressions, the AED or cardiac monitor will be used to determine if defibrillation is necessary.

High Performance CPR also requires training. Rescuers need to know what to do in advance of the SCA so they can instinctively perform the job. Some additional requirements of High Performance CPR are as follows:

Ensuring minimal interruptions of chest compressions

When performing chest compressions, the rescuer must maintain an optimal rate of between 100 and 120 compressions per minute. These compressions must also be at the appropriate depth for the patient’s age group:

  • Infant: 1 ½ inches
  • Child: 2 inches
  • Adult: 2-2.4 inches

The rescuer must allow for full chest recoil and keep his or her hands in contact with the chest at all times without leaning on the chest to ensure maximum recoil and increased negative pressure in the thoracic cavity.

Controlled ventilations

In the absence of an advanced airway, providers should administer two ventilations for every 30 compressions. The rescuer should stop ventilation when they see the chest begin to rise.

It should take no longer than 3 seconds to administer two ventilations.

If you have inserted an advanced airway, one ventilation should occur every 6 seconds independent of chest compressions.


If using an AED, rescuers must wait to push the “analyze” button until the chest compressions have stopped to ensure the device analyzes the cardiac rhythm correctly. Any movement of the patient can mean an incorrect analysis, thus resulting in an unnecessary defibrillation or a missed opportunity to defibrillate.

If you use a manual defibrillator, make sure that the device is pre-charged at the 1-minute, 45-second mark.

The goal is to minimize the perishock pause, so the total pre-shock and post-shock pause time comes to less than 5 seconds. If the defibrillation proves necessary, responders can administer it quickly. If the patient’s cardiac rhythm does not require defibrillation, the charge can be dumped.

The American Heart Association’s Emergency Cardiovascular Care (ECC) also requires a minimum chest compression fraction time of 60%. This number is extremely low.

If High Performance CPR is implemented, emergency medical systems can easily see an increase in chest compression fraction to 80% or 90%. This increase in chest compressions should result in an increased number of successful resuscitations.

Minimally Interrupted Cardiac Resuscitation

Minimally Interrupted Cardiac Resuscitation (MICR) sometimes goes by another name as well: Cardiocerebral Resuscitation (CCR).

Arizona has used this practice for several years. MICR requires that rescuers perform 200 compressions over 2 minutes, ensuring appropriate compression depth while allowing for full recoil. After each set of 200 compressions, if necessary, providers administer an analysis and defibrillation along with 1 mg of epinephrine.

Responders repeat this for four rounds, then switch to following the AHA Advanced Cardiac Life Support (ACLS) algorithm if the patient does not have a Return of Spontaneous Circulation (ROSC).

Bentley J. Bobrow, a physician at the Arizona Mayo Clinic, conducted a prospective study in two metropolitan cities and surrounding communities. Bobrow found that the survival-to-hospital discharge increased from 1.8% to 5.4% in a group of 886 patients in SCA.

For information on High Performance CPR or the Pit Crew concept, join us in either the 24-hour Live EMT Refresher or the Live 48-hour EMS refresher courses.