High-quality chest compressions and early defibrillation are the cornerstones of effective cardiac arrest care.1 When implemented correctly these two interventions enhance patient outcomes and improve overall survival.2 However, despite simplified advanced cardiac life support (ACLS) algorithms and extensive training of providers, cardiac arrest scenarios in the emergency department (ED) are still high-stress and mortality rates remain high.3,4 

In addition, ED providers often prioritize other therapies and procedures that have not shown similar survival benefit. What if we could simplify our approach while simultaneously improving patient outcomes?

Team Focused CPR

Team Focused Cardio-Pulmonary Resuscitation (TFCPR) is a choreographed approach to cardiac arrest resuscitation where providers know and practice their specific, individualized roles in order to optimize CPR performance, quality, and outcomes.5  De-emphasis is placed on endotracheal intubation (ETI), intravenous (IV) drug administration, and any other intervention that could potentially distract from effective, high-quality CPR.

How Does TFCPR Work

Figure 1. Schematic for provider positioning during TFCPR used at Carolinas Medical Center. RT = respiratory therapist, RN = registered nurse, MD = emergency medicine physician. MD1 and MD2 are typically residents. POCUS = point-of-care ultrasound; SAD = supraglottic airway device.

  • Chest compressions are performed in cycles of 200 at a rate of 100-120/min, changing out compressors at the start of each new cycle.67 The compressor counts out loud at each 20th compression (i.e. 20-40-60-80-etc.) to keep the team on pace.
  • Ventilated breaths are administered with each 20th compression to avoid hyperventilation and gastric overinflation.
  • After the 180th compression, the defibrillator is pre-charged [prior ALiEM post on precharging the defibrillator].8 A team member’s finger is also placed on the femoral pulse, allowing confirmation of mechanical pulsations with chest compressions and facilitating detection of ROSC after compressions are stopped.
  • After the 200th compression, cardiac rhythm analysis occurs simultaneously with pulse check. If appropriate, shock can be delivered immediately and the next cycle of compressions resumed without delay. Important: The goal time without compressions is less than 10 seconds.9,10

In TFCPR, the use of bag-valve-mask (BVM) or blind-insertion supraglottic airway device (SAD) is encouraged over ETI to avoid any unnecessary pauses.11 If IV attempts are not immediately successful, then intraosseous (IO) lines are placed without hesitation.12,13 Epinephrine administration is automatically timed with every other cycle of 200 compressions, streamlining its delivery.

When point-of-care ultrasound (POCUS) is utilized, it is performed during pulse checks and should never delay resumption of the next compression cycle.14 Central venous and arterial lines are not inserted intra-arrest due to high distraction potential and minimal added benefit.15 Finally, end-tidal CO2 monitoring is universally encouraged, as well as audiovisual CPR feedback tools with code leader observation and coaching to ensure chest compressions are optimal.16–18 

Prehospital Success

Widespread incorporation of TFCPR by North Carolina EMS agencies began in 2011 with a statewide protocol launching in 2012. A retrospective cohort analysis of 14,129 out-of-hospital cardiac arrest (OHCA) patients in North Carolina from 2010-14 was recently published in Resuscitation.19 Survival with good neurological outcome was significantly higher in the TFCPR cohort (8.3%) vs. standard CPR cohort (4.8%) for all patients suffering any type of OHCA. Neurologically-intact survival for witnessed OHCA with initial shockable rhythm was also significantly higher with TFCPR (28.9%) vs. standard CPR (16.8%). Statistically significant increases in overall survival to hospital admission and overall survival to hospital discharge were also seen between the two cohorts.19

Table 1. Outcomes of TFCPR vs. standard CPR for out of hospital cardiac arrest (OHCA) in North Carolina from 2010-14 based on 14,129 total patients (10,104 patients in TFCPR cohort, 4,025 patients in standard CPR cohort) 19


Individual departments may need to assign different roles or responsibilities to different providers, but the strength of TFCPR is in its simplicity and adaptability to almost any clinical setting by focusing on a few key principles:

  • Structured framework of chest compression cycles
  • Rehearsed and pre-assigned roles/responsibilities to reduce chaos and confusion
  • Streamlined peri-shock pause with pre-charging of the defibrillator
  • SAD and IO usage to decrease chest compression interference
  • Minimization of advanced interventions to limit distraction (also decrease resource utilization)

As an example, the emergency medicine residency at Carolinas Medical Center (Charlotte, NC) recently incorporated TFCPR as the departmental standard for cardiac arrest. Initial provider training was simple and consisted of 2 phases:

  1. 10-minute online training module
  2. 15-minute hands-on simulation with manikin and full code team

Final Thoughts

TFCPR is an established cardiac arrest protocol with proven results in the prehospital setting. Required resources are minimal, and potential benefit substantial. Consider incorporating these principles into your emergency departmental standards for cardiac arrest resuscitation.

Blake Johnson, MD

Blake Johnson, MD

Department of Emergency Medicine
Carolinas Medical Center
Blake Johnson, MD

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David Pearson, MD

David Pearson, MD

Associate Professor
​Associate Residency Director
​Director of Cardiac Arrest Resuscitation​​
Department of Emergency Medicine
Carolinas Medical Center
David Pearson, MD

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