Study guide
7.1 High-Quality CPR Metrics
AHA PALS Provider Pediatric Advanced Life Support
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1 Chapter 1: Course Overview & Exam Logistics
1.1 Current Exam Facts 1.2 Audience, Prerequisites & Study Plan
2 Chapter 2: Systematic Pediatric Assessment
2.1 Pediatric Assessment Triangle (PAT) 2.2 Evaluate–Identify–Intervene Sequence 2.3 Primary Assessment: ABCDE 2.4 Secondary Assessment, SAMPLE & Vitals by Age
3 Chapter 3: Respiratory Distress & Failure
3.1 Respiratory Distress vs Failure 3.2 Recognition & Immediate Intervention Priorities 3.3 Oxygen Delivery & Basic Airway Support
4 Chapter 4: Airway Problems & Ventilation Strategies
4.1 Upper Airway Obstruction 4.2 Lower Airway, Lung Tissue Disease & Disordered Control 4.3 Bag-Mask Ventilation & Advanced Airways During CPR
5 Chapter 5: Shock Fundamentals & Hypovolemia
5.1 Compensated vs Hypotensive (Decompensated) Shock 5.2 Hypovolemic Shock 5.3 Isotonic Fluid Bolus 10–20 mL/kg & Reassessment
6 Chapter 6: Distributive, Cardiogenic & Obstructive Shock
6.1 Distributive & Septic Shock Pathway 6.2 Cardiogenic Shock 6.3 Obstructive Shock
7 Chapter 7: Pediatric BLS & High-Quality CPR
7.1 High-Quality CPR Metrics 7.2 Compression-Ventilation Ratios 7.3 CPR Quality Monitoring: ETCO2 & Diastolic BP
8 Chapter 8: Pediatric Cardiac Arrest Algorithm
8.1 Arrest Recognition & Systematic Approach 8.2 VF/pVT & Defibrillation Energy 8.3 Asystole & PEA 8.4 Epinephrine in Arrest: Dose & Timing
9 Chapter 9: Bradycardia & Narrow-Complex Tachycardia
9.1 Bradycardia with Poor Perfusion 9.2 Sinus Tachycardia vs SVT 9.3 Stable SVT: Vagal Maneuvers & Adenosine
10 Chapter 10: Unstable Tachycardia & Wide-Complex Rhythms
10.1 Unstable Tachycardia & Synchronized Cardioversion 10.2 Wide-Complex Tachycardia & VT with Pulse 10.3 Antiarrhythmics for Tachycardia with Pulse
11 Chapter 11: Reversible Causes & Special Circumstances
11.1 Reversible Causes: The H's and T's 11.2 Special Circumstances at Exam Level 11.3 Extracorporeal CPR (ECPR) Overview
12 Chapter 12: Post–Cardiac Arrest Care
12.1 Post-ROSC Oxygenation & Ventilation 12.2 Post-Arrest Hemodynamic Support 12.3 Temperature Control & Glucose 12.4 Neuroprognostication & Transport
13 Chapter 13: Vascular Access & Core Pharmacology
13.1 IV and Intraosseous Access 13.2 Epinephrine Dosing in Depth 13.3 Amiodarone, Lidocaine & Adenosine 13.4 Weight-Based Dosing Aids & Drugs to Avoid Routinely
14 Chapter 14: Team Dynamics & Megacode Readiness
14.1 High-Performance Team Roles 14.2 Closed-Loop Communication 14.3 Constructive Intervention, Debriefing & Exam Integration
7.1 High-Quality CPR Metrics
Key Takeaways Explain This Topic AI
High-quality pediatric CPR uses a compression rate of 100–120/min, depth of at least one-third the anteroposterior chest diameter (~1.5 in/4 cm in infants; ~2 in/5 cm in children), full chest recoil, and pauses under 10 seconds.
Minimize interruptions, avoid excessive ventilation, and maximize chest compression fraction—high-quality metrics drive coronary and cerebral perfusion more than any single drug.
For infants (2025), use either the heel of one hand or the 2 thumb–encircling hands technique—the guidelines do not rank them—and use heel-of-one-hand whenever the rescuer cannot encircle the chest; the historic 2-finger technique is no longer a primary recommended method because it often fails depth targets.
For children, use one or two hands on the lower half of the sternum as needed to achieve depth without leaning.
When the rescuer is able and willing, conventional CPR (compressions plus breaths) is preferred over compression-only CPR for infants and children; 100% oxygen during CPR is reasonable.
Last updated: September 2026
Why Metrics Matter More Than Memory of a Drug Dose
High-quality CPR underpins every pediatric arrest algorithm and supports defibrillation, epinephrine, and airway management. It is a core course skill rather than a published percentage of written questions; nearly every arrest algorithm assumes high-quality CPR as the platform under defibrillation, epinephrine, and airway management. Poor compressions produce inadequate coronary perfusion pressure; no antiarrhythmic can fix that. On skills stations and written items, you are tested on whether you can state and apply the rate–depth–recoil–interruptions–ventilation package, not only on joules and milligrams.
High-quality CPR creates artificial circulation. Each compression raises intrathoracic pressure and squeezes the heart and great vessels; full recoil allows venous return into the thorax so the next compression has volume to eject. Leaning on the chest, shallow pushes, rates outside the target band, and long pauses for pulse checks, intubation, or IV attempts all lower coronary and cerebral blood flow. Your job is to protect the compression engine while the team layers advanced care around it.
The five core metrics (memorize as a checklist)
Metric Pediatric target Why it fails on exams/skills
Rate 100–120 compressions/min Too slow underperfuses; too fast shortens diastolic filling and often reduces depth
Depth ≥1/3 AP chest diameter (~ 1.5 in / 4 cm infant; ~ 2 in / 5 cm child) Shallow compressions are the most common skill error
Recoil Full chest rise between compressions; no leaning Leaning prevents venous return
Interruptions Pauses <10 seconds ; minimize all stops Long pulse checks, slow defibrillator charging, and chatter during switches
Ventilation Visible chest rise only; avoid excessive rate/volume Hyperventilation raises intrathoracic pressure and drops venous return
These metrics apply whether the child is in the field, the ED, or the PICU. Advanced monitors (Section 7.3) refine quality; they do not replace the basic checklist.
- Rate, Depth, and Recoil in Detail
- Rate: 100–120/min
Push hard and fast , but not recklessly fast. The accepted band is 100 to 120 compressions per minute . Below 100, flow falls. Above 120, rescuers often sacrifice depth and recoil. Metronomes, feedback devices, and team coaching ("you're at 110—hold that") help keep rate honest under stress. Change the compressor about every 2 minutes (or sooner if fatigue shows)—fatigue silently degrades depth and rate long before the rescuer admits it.
Depth: one-third of the anteroposterior diameter
Depth is age-linked but rule-based:
Infants: compress at least one-third of the AP chest diameter, approximately 1.5 inches (4 cm) .
Children: compress at least one-third of the AP diameter, approximately 2 inches (5 cm) .
Adolescents who have reached puberty (adult-size chest) follow adult depth targets on many algorithms; for prepubertal children, stay with the pediatric one-third / ~2 in rule.
Depth is measured at the lower half of the sternum , not the xiphoid tip and not the upper sternal notch. Allow the chest to return fully after each push; incomplete recoil is as harmful as inadequate depth because diastolic filling fails.
Full recoil and no leaning
After every compression, lift your weight completely so the sternum returns to its natural position. Hovering palms that rest on the chest between pushes count as leaning. Teach teammates to watch the chest wall—if it never fully rises, call it out with constructive intervention ("full recoil").
Minimize interruptions and protect chest compression fraction
Chest compression fraction (CCF) is the proportion of arrest time spent actually compressing. Higher CCF correlates with better outcomes. Practical rules:
Limit pulse checks to ≤10 seconds (healthcare providers).
Pre-charge the defibrillator and clear early so the post-shock pause is brief.
Switch compressors efficiently during planned rhythm checks.
Do not stop compressions for prolonged IV attempts if IO is available, or for leisurely intubation when bag-mask is effective.
Keep all pauses—including intubation attempts and compressor switches— under 10 seconds whenever possible.
Avoid excessive ventilation
During CPR, give only enough volume for visible chest rise . Rapid, forceful bagging inflates the stomach, increases intrathoracic pressure, reduces venous return, and can lower coronary perfusion pressure. Coordinate breaths with the ratio in Section 7.2 until an advanced airway allows asynchronous ventilation—still without hyperventilation.
Loading diagram... High-Quality Pediatric CPR Checklist
- Hand Technique: Infant vs Child (2025 Update)
- Infants (<1 year, excluding newborns in NRP)
2025 AHA/AAP pediatric BLS updated infant compression technique because the historic two-finger method frequently failed to achieve adequate depth:
The 2025 recommendation names two acceptable techniques and does not rank them : rescuers should compress the sternum using either the 1-hand technique (heel of one hand) or the 2 thumb–encircling hands technique. It adds one conditional rule— if the rescuer cannot physically encircle the chest, compress with the heel-of-1-hand technique.
Technique When / how Notes
2 thumb–encircling hands Acceptable whenever you can encircle the chest (often easier with two rescuers) Thumbs side-by-side or stacked on lower sternum; fingers encircle the thorax
Heel of one hand Equally acceptable, and recommended when the chest cannot be encircled Heel on lower half of sternum; push hard to one-third depth
2-finger technique Not a primary 2025 recommendation Dropped as a taught method because of inadequate depth in practice
The exam-relevant shift is the disappearance of the two-finger method, not a new hierarchy between the other two. Choose whichever of the two you can perform to full depth on the patient in front of you; if your hands cannot encircle the infant’s chest, use the one-hand heel method rather than defaulting to weak two-finger pushes.
Children (1 year to puberty)
Use one or two hands on the lower half of the sternum. One hand may suffice for a small toddler if depth is achieved; use two hands when needed for force without compromising rate or recoil. Position yourself so shoulders are over the sternum and elbows lock to use body weight rather than arm fatigue alone.
Surface and positioning
Compress on a firm surface . Soft mattresses absorb force and steal depth—use a backboard when available in-hospital. For infants, support the body so the head is not dangling; maintain a patent airway between compression cycles when providing breaths.
Conventional CPR Preferred; Oxygen During Arrest
Pediatric arrest is often asphyxial (respiratory failure preceding bradycardia and asystole/PEA). That physiology is why conventional CPR—chest compressions plus rescue breaths or bag-mask ventilation —is preferred over compression-only CPR when the rescuer is able and willing to provide breaths. Compression-only CPR is still better than no CPR for lay rescuers who cannot or will not ventilate, but PALS providers and trained rescuers should plan for compressions and ventilations .
During CPR it is reasonable to use 100% oxygen (highest feasible FiO2). The priority in arrest is maximizing oxygen delivery to ischemic tissues; titration strategies that avoid hyperoxia apply more clearly after ROSC (Chapter 12), not as a reason to withhold high FiO2 while the child is pulseless.
Clinical scenario (synthesis)
A 4-month-old is found unresponsive and apneic; no pulse is felt within a 10-second check. You start CPR immediately: 2 thumb–encircling compressions at 100–120/min to about 1.5 inches (4 cm) / one-third depth , full recoil, coordinated breaths for visible chest rise, high-flow oxygen on the bag, and pauses kept under 10 seconds for rhythm/pulse checks. A teammate who offers "two-finger compressions only because it's an infant" needs constructive correction to current 2025 technique. If a single rescuer cannot encircle the chest, switch to the heel of one hand —not shallow fingertips.
Master rate, depth, recoil, interruptions, ventilation restraint, and age-correct hand position, and you own the foundation for every arrest algorithm that follows in Chapters 8–11.