What are the main principles of cardiopulmonary resuscitation (CPR) in the hospital setting, including practical setup?

Main Principles of CPR in Hospital: Practical Setup

In-hospital CPR should follow a structured team-based approach with immediate activation of the code team, high-quality chest compressions at 100-120/min and depth of at least 2 inches (5 cm), early defibrillation for shockable rhythms, and minimal interruptions in compressions while establishing IV/IO access and advanced airway management. 1

Initial Recognition and Team Activation

The moment cardiac arrest is identified in the hospital setting, the response differs fundamentally from out-of-hospital scenarios due to immediate resource availability:

• Verify scene safety first - ensure the environment is safe for rescuers 2
• Check for responsiveness while simultaneously assessing for normal breathing and pulse (no more than 10 seconds) 1
• Immediately activate the emergency response system (code team) - in hospitals with multiple rescuers available, one person stays with the patient while another activates the code and retrieves emergency equipment 2
• Shout for nearby help to mobilize additional staff 2

High-Quality Chest Compressions: The Foundation

Chest compressions are the absolute priority and must begin immediately upon confirming cardiac arrest. 1, 3 The quality metrics are non-negotiable:

Compression Technique

• Depth: At least 2 inches (5 cm) for adults, pushing hard and fast 1
• Rate: 100-120 compressions per minute 1
• Allow complete chest recoil between compressions 1
• Position the patient's torso at approximately the level of the rescuer's knees - this optimizes compression delivery 4, 5
• Perform CPR on a firm surface whenever possible 5

Minimizing Interruptions

• Minimize interruptions in compressions - this is critical for maintaining coronary and cerebral perfusion 1, 3
• Change compressor every 2 minutes or sooner if fatigued to maintain quality 1
• Continue compressions during rhythm checks except for the brief moment of actual rhythm analysis 1

Common Pitfall

Avoid excessive ventilation, which is a frequent error that decreases venous return and cardiac output 1. The focus must remain on uninterrupted, high-quality compressions.

Compression-to-Ventilation Ratios

For healthcare providers in the hospital, perform 30 compressions to 2 breaths until an advanced airway is placed 1. This applies to both cardiac and non-cardiac causes of arrest 4.

Once an advanced airway (endotracheal tube or supraglottic airway) is established:

• Provide continuous chest compressions without pauses
• Deliver 1 breath every 6 seconds (10 breaths per minute) 1
• Give enough tidal volume to produce visible chest rise while avoiding hypo- and hyperventilation 4, 5

Defibrillation Strategy

Early defibrillation is critical for shockable rhythms (VF/pulseless VT). 1

Rhythm Check and Shock Delivery

• Check rhythm every 2 minutes during CPR cycles 1
• If VF/pulseless VT is identified:
  • Deliver one shock immediately 1
  • Biphasic: 120-200 Joules (manufacturer recommendation); if unknown, use maximum available 1
  • Monophasic: 360 Joules 1
• Resume CPR immediately for 2 minutes after shock delivery without pulse check 1

For Non-Shockable Rhythms (PEA/Asystole)

• Resume CPR immediately for 2 minutes 1
• Focus on identifying and treating reversible causes 1

Vascular Access and Medications

Establish IV or IO access as soon as feasible without interrupting compressions 1:

Epinephrine

• 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms 1
• Continue throughout the resuscitation 1

Antiarrhythmics for Refractory VF/pulseless VT

• Amiodarone: First dose 300 mg bolus, second dose 150 mg 1
• Lidocaine (alternative): First dose 1-1.5 mg/kg, second dose 0.5-0.75 mg/kg 1

Advanced Airway Management

Airway management is secondary to high-quality compressions. 6

• Consider endotracheal intubation or supraglottic advanced airway only after initial CPR cycles 1
• Use waveform capnography to confirm and monitor ET tube placement 1
• Minimize interruptions in compressions during intubation attempts - if intubation cannot be accomplished quickly, resume compressions and retry after the next cycle 6

Critical Point

Do not delay or interrupt compressions for prolonged intubation attempts. Bag-mask ventilation with good technique is acceptable until the airway can be secured efficiently 6.

Monitoring for ROSC

Assess for return of spontaneous circulation by checking for 1:

• Pulse and blood pressure
• Abrupt sustained increase in PETCO2 (typically ≥40 mmHg) - this is often the earliest indicator
• Spontaneous arterial pressure waves with intra-arterial monitoring

Reversible Causes: The H's and T's

Systematically search for and treat reversible causes throughout the resuscitation 1:

H's:

• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hypo-/hyperkalemia
• Hypothermia

T's:

• Tension pneumothorax
• Tamponade (cardiac)
• Toxins
• Thrombosis (pulmonary)
• Thrombosis (coronary)

Team Dynamics and Quality Improvement

Use real-time feedback devices during CPR to improve compression quality - this is now recommended based on evidence showing improved CPR performance 5. These devices monitor compression rate, depth, and recoil.

Mechanical CPR devices are NOT routinely recommended for in-hospital cardiac arrest, as they show no survival benefit over high-quality manual CPR 4, 5, 3. They may be considered only in specific circumstances where manual CPR cannot be maintained (e.g., during transport) 5.

Team Coordination

• Assign clear roles: compressor, airway manager, medication administrator, recorder, team leader 7
• Brief and debrief the team before and after resuscitation events to improve performance 7
• Use data from arrests for feedback during debriefings 7

Practical Setup Summary

1. Patient positioning: Supine on firm surface, torso at rescuer's knee level
2. Immediate actions: Verify arrest → Call code team → Start compressions
3. Equipment retrieval: Defibrillator/monitor, airway equipment, code cart
4. Compression priority: 100-120/min, ≥2 inches depth, minimal interruptions
5. Early defibrillation: For shockable rhythms within 2-minute cycles
6. Medication access: IV/IO for epinephrine every 3-5 minutes
7. Airway management: Secondary to compressions, use capnography
8. Systematic approach: Address reversible causes throughout

This algorithmic approach, based on the 2020 and 2025 AHA Guidelines, prioritizes the interventions most likely to improve survival: high-quality compressions, early defibrillation, and systematic treatment of reversible causes 1, 4, 5.