The Five Second Rule – Six Ways you can Reduce Pauses in Compressions and Save More Lives with CPR

If you’ve been staying awake in your CPR classes for the last few years, you know that quality chest compressions and defibrillation are the only things proven to actually revive victims of cardiac arrest. Study after study has shown that any time not spent compressing the heart is time generally wasted on otherwise unproductive tasks. The blood simply needs to keep moving if we expect to have any success at all in trying to restart someone’s heart and produce meaningful survival.

Every healthcare provider should know this, but a lot of them don’t really realize how much time spent not doing compressions adds up. They should. Since every second without adequate blood flow gravely harms a patient, seconds really count. To help with this, I’d like to introduce you to what I call the “5 Second Rule” and give you a few tips on how you can keep your pauses in compressions during resuscitation under 5 seconds at a time.

This 5 Second Rule is pretty simple and unlike the other 5-second rule that assumes that all germs have decided to be nice and not infest a piece of food dropped on the floor if you pick it up up quick enough, this rule actually makes sense and can make a big difference in the care we provide our patients. I propose that we all try to limit any and all pauses in compressions during CPR to 5 seconds or less. It’s very possible, but it’s both harder and easier to do than it sounds. We all pause compressions for longer than we think we do and those seconds come back to haunt us in terms of lower survival rates. My recent post covering the “Pre-Clear” method of reducing the perishock pause covers a study that shows a 14% to 18% drop in survival for every 5 seconds compressions were paused waiting for a shock to be given. That’s a big deal.

In order to help us think about this issue, I’ve come up with a list of ways you can make a difference in your next cardiac arrest resuscitation. Some of these are things you’ve heard of but some of them are things you may not have. All of them are easy to do and can help you make a big difference in your patients’ lives. Let’s get to it.

1. Use a Metronome – The first letter of the “MCMAID” resuscitation protocol stands for “Metronome” or one of those things that make a rhythmic clicking noise used by musicians to keep time. It is absolutely amazing the effect that one of these things will have on your CPR performance. Turn it on 100bpm, set it next to your patient, and time your compressions to the beat.

 2. Run Your CPR Sector Like a Pit Crew – There is a lot written about the “Pit-Crew” method of resuscitation that takes its cues from the choreographed movements of a race car’s maintenance crew. Watching them work is a thing of beauty. Their movements are deliberate yet rapid. No time is wasted because in their business even fractions of seconds count towards succeeding or failing at their end result. The people doing your chest compressions should have similar precision. Use both sides of the patient, if possible, and switch out compressors every 1 to 2 minutes (100 or 200 compressions) at the minute mark. When one pair of hands leaves the chest, the next should be ready to go. Stop, shock, go… under 5 seconds. It requires a bit of practice but you can gain a lot of benefits by practicing your rotations.

3. Charge the Defibrillator before You Stop Compressions – The American Heart Association came out with this really good idea in their last revision of the guidelines and while you may have heard of it, perhaps you don’t quite know how much of a difference it makes. I timed my monitor as it charged up to 360 joules during a routine test. It took 8.3 seconds to go from 0 to 360j. Those 8.3 long seconds are already past our 5 second goal and if you are waiting for compressions to stop so you can clear the patient before you charge, you’re already missing your target. Charge the defibrillator before every scheduled pause in compressions whether you need it or not. That way, when you pause to switch compressors at the 1 or 2 minute mark you can take a quick look at the monitor to make your “Shock or No-Shock” decision, shock immediately if needed, and get right back on the chest. There is little danger in doing this, even though I’ll admit that it takes a bit of getting used to. Don’t make your patient’s heart and brain wait those 8.3 seconds, pre-charge the defib.

4. Use the Pre-Clear In a previous post, I brought forth the idea of the “Pre-Clear” in cardiac arrest. This is where personnel who aren’t the one person providing chest compressions are trained to clear themselves from touching the patient 10 seconds before compressions cease during a scheduled pause. This way, once the compressions stop a shock can be delivered without waiting the 3 seconds it takes to say “I’m clear. You’re clear. Everybody’s clear” and push the shock button. I’ve decided to take this a step further and say that the only people touching a patient should be the ones actively providing a needed intervention. It’s ok to touch the patient if you’re starting an IV or IO line, providing airway management, or another critical task, but keep your hands off otherwise. This way you’re always clear when you need to be. Stay clear of the patient, don’t delay the shock because you’re being too “touchy-feely.”

5. Don’t Check for a Pulse or Look at the Monitor after a Shock – Just start pumping right away. Don’t waste time checking for a pulse or looking at the monitor after a defibrillation shock is given. This is an unnecessary 5-10 seconds that could be spent moving the patient’s blood. Check the pulse if you see a rhythm change during your next scheduled pause in compressions but don’t increase your post-shock pause by looking or feeling. Resist the urge. Use Waveform Capnography (ETCO2) to see when the heart starts pumping again, a Return of Spontaneous Circulaton (ROSC) makes the ETCO2 spike up significantly. You’ll know it when you see it. Also, if you’re not sure if there is a pulse or not, assume there isn’t and start pumping.

6. Seriously, Get Right Back on the Chest – Saying the words “Back on the Chest!” after a shock takes a full second, why wait? Once the person on the monitor presses the “shock” button, the new compressor should immediately start pumping. Electricity moves at the speed of light. Humans are much slower. There is absolutely no chance that the compressor will get a shock. It’s safe, just go.

In addition to all of the above, EMS providers should almost always be working the code where they find the patient. Move the patient to a more open area if you have to, but transporting a victim of cardiac arrest with compressions ongoing is almost certainly a death sentence. Why transport? There is no magical treatment at the hospital that cannot be provided on scene with a well trained and equipped ALS ambulance crew. You can improve your survival rates markedly simply by not transporting until the patient achieves ROSC.

As with everything, practice makes perfect. Practice these steps with your team and talk about them often. You’ll be amazed at how much of a difference these little changes can make. Shaving Seconds Saves Lives. Your survival to discharge rates will thank you.


  • Callaghans1

    An excellent list. The only hesitation I have is with step 3 – pre-charging during compressions. Trusting the electronics of the defibrillator to not discharge early seems to be a clear potential
    danger. It would be interesting to know the risks Vs benefits of this situation as safety for the paramedics must always come first.

    • Robin

      We use Life-pak 15 monitors.. You can precharge with no risk to rescuers.. If will not discharge unless you push the shock button.. If the patient is not in a shockable rhythm at the check… You just dont push the shock button and the monitor just absorbs the shock.. Samething with medtronic physio Semiautomatic AEDs

  • Topdog

    We do need to be certain that there is no chance of the electronics firing whilst charging. Several of my colleagues will not continue compressions whilst charging unless we get some sort of assurance from the manufacturers.

  • Barefoot in MN

    I wonder if the dr’s hands (presumably gloved) were the only point of contact, & if the gloves reduced shock transfer to acceptable levels? the other question I have is, would the contact between caregiver & patient reduce the AED shock to unacceptable levels? I have no clue, just askin’.

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