CPR Duration Guidelines: When to Start, Continue, and Stop Resuscitation

Cardiopulmonary resuscitation (CPR) maintains perfusion until return of spontaneous circulation (ROSC) or futility is determined. High-quality compressions are paramount.

When to Start

• Unresponsive, no normal breathing (agonal gasps = not breathing), no pulse (lay rescuer: skip pulse check).
• Immediately begin compressions (push hard, fast, center of chest, 100–120/min, 5 cm depth, full recoil).

When to Continue

Out-of-Hospital Cardiac Arrest (OHCA):

• Until ROSC (breathing, movement, pulse).
• Until AED available → analyze/shock per prompts.
• Until EMS arrives and assumes care.
• Until rescuer exhaustion (rotate every 2 min if multiple rescuers).
• Do not stop for pulse checks during compressions (interrupts perfusion). AED analyzes every 2 min.

In-Hospital Cardiac Arrest (IHCA):

• Follow ACLS algorithms. Continue until ROSC or team decision to terminate.
• Termination criteria (generally): Asystole/PEA > 20 min reversible causes excluded (Hs & Ts), ETCO₂ < 10 mmHg despite optimal CPR, no ROSC after prolonged effort.
• Consider: age, comorbidities, downtime, initial rhythm, ETCO₂ trend, POCUS cardiac activity.

When to Stop (Termination of Resuscitation)

• BLS TOR Rule (OHCA, EMS-witnessed): No ROSC, no shock delivered, unwitnessed by EMS → consider termination.
• ALS TOR Rule: No ROSC, no shocks, unwitnessed by bystander, no AED shock → terminate.
• Physician judgment: futility, irreversible cause, patient wishes (DNR/POLST), family presence.
• Never stop for: hypothermia (core < 30°C), drowning (cold water), pregnancy (perimortem C-section), toxicologic (may need prolonged support), ECMO candidacy.

Quality Metrics

• Chest compression fraction > 80%.
• Compression depth 5–6 cm, rate 100–120.
• Minimize interruptions (< 10 sec for rhythm check).
• ETCO₂ monitoring: > 10–15 mmHg during CPR correlates with ROSC.

CPR buys time. High-quality, uninterrupted compressions + early defibrillation save lives.