Pit Crew CPR – The Explicit Details

pitcrew

I’ve given an overview of my department’s Pit Crew CPR process many times at ems12lead.com, our Facebook page, the Resuscitation group, and various conferences around the country.

(See also: Why do we send so many people to a cardiac arrest?)

Even so, I’m frequently asked for specific details. People want to know exactly how we do it. Here is a very simple description of HHIFR’s Pit Crew CPR process in bullet point form (recently updated). It helps to think of it as a 4-phase process.

cardiac arrest picklist

Phase 1: Patient’s side to first shock

  • Confirm pulselessness and announce “at patient, code blue”
  • Start CPR – continuous chest compressions at the appropriate rate, depth, and recoil
  • Power on the Lifepack 12, push the LEAD button, spin the dial to the right, and select the cardiac arrest picklist
  • Extend the cables, attach the combipads, and coordinate the application of the pads with the rescuer on chest compressions
  • Immediately after applying the second pad you should know whether or not the rhythm is shockable
  • Charge the capacitor without interrupting chest compressions
  • Once the defibrillator is charged, announce “Stop CPR”
  • The person on chest compressions should “show hands” to indicate they are clear
  • Note: “I’m clear, you’re clear, we’re all clear” should be completely gone at this point in time
  • Push the shock button
  • Resume immediate post-shock compressions

Phase 2: First 2-minute cycle after the first shock

  • Post-shock compressions should already be happening
  • Deploy and test the suction unit
  • Assemble the BVM
  • Attach capnography between mask and bag
  • Attach capnography circuit to Lifepak 12
  • Attach BVM to oxygen
  • Insert an OPA
  • You should now switch to 30:2
  • Note: “Upstroke ventilations” after each 10th compression requires a lot of practice! This is not the same as 10:1 so stick with 30:2.
  • Pay attention to your initial ETCO2 reading!

Phase 3: “The Seattle Switch” (No offense to any city or department that does it the same way)

  • At the 1:45 mark you should be thinking about the next defibrillation
  • Tip: If you are doing 30:2 you can see the heart rhythm during ventilations
  • Ask, “Who is next on chest compressions?” That person should line up behind the rescuer doing CPR
  • Pre-charge the defibrillator without interrupting chest compressions
  • As soon as the defibrillator starts charging the airway person should remove the BVM from the patient’s face
  • Once charged, announce “Stop CPR”
  • The person doing chest compressions should clear out of the way (this is the start of the peri-shock pause)
  • The person on the monitor should quickly verify the rhythm is shockable and press shock
  • Once the shock is delivered (or rhythm is non-shockable), announce “Continue CPR”
  • The new rescuer starts compressions (this is the end of the peri-shock pause and the start of a new 2-minute cycle)
  • Note: To “dump” the charge on the Lifepak 12 simply press the selector button (not the shock button)
  • IVs, drugs, and advanced airway procedures are acceptable provided that they do not interfere with expertly performed BLS!
  • Once an advanced airway is in place you should deliver asynchronous ventilations every 6 seconds (that’s slow)
  • For “non-responders” to Pit Crew CPR (> 5 cycles and still no ROSC) consider switching to LUCAS

checklist

Phase 4: Post-resuscitation care checklist

  • Once ROSC is identified (sudden rise in ETCO2, organized rhythm on the monitor, verified with pulse check)
  • Attach pulse oximetry and continue ventilating (maintain SpO2 at 96-99%)
  • Obtain blood pressure
  • Obtain baseline temperature
  • Obtain 12-lead ECG
  • Perform mini-neuro exam (Can the patient follow commands?)
  • Announce “Code STEMI” and/or “Code ICE”
  • Re-evaluate the airway
  • Consider additional IV/IO lines
  • Being external cooling and iced saline if indicated
  • Consider applying LUCAS as a precaution
  • Set VT/VF alarm and check oxygen
  • Safely convey the patient to the hospital
  • If the patient re-arrests: remain calm, pull over in a safe place, start CPR, charge the defibrillator, deliver shock, provide post-shock compressions

Good teamwork, excellent communication, smooth transitions, and mutual respect are the keys to success.

Work the cardiac arrest on scene until ROSC whenever possible, especially for patients with a “good story” (i.e., witnessed collapse, bystander CPR, initial shockable rhythm). Moving them during the “sweet spot” of the code will reduce the odds of a successful resuscitation.

Try not to accomplish too much too fast! The wheels can come off the wagon when too many rescuers jump in all at once, so put people to work in a way that enhances, and does not overwhelm the Pit Crew CPR process. You can always get in line to be next on chest compressions.

You can practice “The Seattle Switch” with your crew using nothing but a couch cushion. It’s a happy coincidence that we shock on a 2-minute cycle and we also change out the person out on chest compressions every 2 minutes. By combining these two activities you can minimize unnecessary delays in CPR and maintain your peri-shock pauses to 5 seconds or less.

As a final thought, it doesn’t have to be perfect! It just has to be good enough to save the patient’s life. The “perfect code” doesn’t exist. There will always be opportunities for improvement. As resuscitation legend Mickey Eisenburg, M.D. is fond of saying, “Measure, improve, measure, improve….”

We’d love to hear about your Pit Crew CPR, High Performance CPR, Choreographed Model, (whatever you prefer to call it). Leave us a comment with your affiliation and how you approach resuscitation!

 

8 Comments

  • Samuel says:

    We also do pit crew CPR (very similar, minor details different) and have found it very very effective. I’m wondering though—if you have a LUCAS device, why wait to put it on? Why not apply it early?

    We practice the placement in such a way that compressions are interrupted for less than 10 seconds. And the benefits we see is that it doesn’t tire out, doesn’t take up extra space.

    Thoughts?

    • Tom Bouthillet says:

      There are several reasons. In the first place, the LINC trial showed that manual CPR and mechanical chest compressions with the LUCAS device are equivalent. So it’s important to start this conversation with the understanding that we aren’t depriving patients of anything proven to be superior.

      Second, please don’t take offense, but having practiced with the LUCAS device extensively, and having watched training videos from several different departments, I do not believe that the LUCAS device can be placed in 10 seconds on a real patient.

      The only evidence I would accept as valid in this regard would be from a high volume system that routinely uses LUCAS and CODE-STAT so they can provide data showing the exact time that elapses from the last manual compression to the first mechanical compression on human subjects. I am aware of one system near Minneapolis that may eventually be able to provide this information.

      In the meantime, we are using LUCAS for “non-responders” to Pit Crew CPR, any patient transported without ROSC, or as an option for patients with ROSC (apply as a precaution in case the patient re-arrests en route to the hospital.)

      I may feel differently about this in the future.

  • Tim says:

    So, I have a question and was wondering what other peoples thoughts are. Some of my thoughts come from reading the following article; http://circ.ahajournals.org/content/111/16/2134.full. I noticed that your allgorithm calls for ventilation every 6 sec, but it seems like more and more in BLS and CPR/cardiac arrest patients, ventilations are becoming less important. Lay person CPR is being taught without ventilations now and although I don’t agree we should be doing this as healthcare professionals, the arguments they use for why this is good enough makes sense to me. Every time you push on the chest during compressions, you cause the patient to exhale and when you release, negative thoracic pressure causes air to move into the lungs, effectively ventilating the patient with approximately 100 small tidal volume ventilations a minute. I guess the argument could be made that you are just moving the air in the deadspace of the lungs back and forth. This is partially why I would not advocate for no ventilations by healthcare professionals, along with needing to reverse hypoxia in patients who have been in cardiac arrest for an extended period of time.
    I guess my question is why we don’t ventilate less frequently, like every 10 seconds instead? I wonder this for the following reasons. Firstly, every time we ventilate, we increase intra-thoracic pressure and decrease venous return to the heart, affecting the cardiac output and perfusion pressures of our compressions. For this reason it would make sense to me to decrease the number of times we ventilate, so we decrease the number of times we affect the efficacy of our compressions. Secondly, in the cardiac arrest state, the amount of oxygen needed by the body is decreased, because the metabolism is significantly slowed, so the amount of oxygen needed by the patient is decreased, so then the amount of oxygen delivered per ventilation should last longer making it plausible to ventilate less often and still adequately oxygenate the patient, especially considering we are giving them a much higher concentration of oxygen than is contained in atmospheric air.
    I like to think of this in terms of the severe asthma or COPD patient who is being ventilated. From what I’ve been told, you ventilate them every 8-10 seconds in order to give them enough time to exhale, so we don’t cause stacked breaths and barotrauma. If this rate of ventilation is adequate to keep them acceptably oxygenated (and I realize this will be patient dependent and not necessarily acceptable for all patients) why would it not be acceptable to keep a cardiac arrest patient adequately oxygenated?
    All of this, has also made me think of the 30:2 ratio. I did some quick math in my head and I came up with 30 compressions taking approximately 18 seconds in order to make 100 compressions in a minute. If the first 15 compressions are needed to establish proper cerebral and coronary perfusion pressures, then only half of our compressions are effective and then we stop for 10+ seconds to ventilate twice, meaning, we only deliver effective circulation 1/3 of the time with this method of CPR. I realize these are the guidelines and we need to follow them, but it makes me think more research is needed.
    Lastly, I have heard it advocated that once an ET tube is in place we should be ventilating on the downstroke of compressions. I believe this is in order to have minimal intrathoracic pressure during the upstroke or filling phase, again so as not to affect venous return to the heart. Now I have also heard this only works for ET tubes, because no other advanced airway/SGA has the occlusion pressures to cause a proper seal to ventilate the patient on the downstroke.
    Anyway, these are my thoughts and I was wondering whether my thoughts make sense to anyone else or just me and what other people’s thoughts are. I only have the data from the above article to support my thoughts and I’m just trying to think critically and incorporate what I have heard from people who are much smarter than I am. If anyone has data to support or refute my thoughts, I would love to see it.

    • Tom Bouthillet says:

      I don’t think many people disagree that for run-of-the-mill, adult sudden cardiac arrest, ventilations are unnecessary for the first 3-4 minutes. After that point there isn’t much consensus.

      We do know that hyperventilation is common for cardiac arrest patients and that it is harmful. Whether you’re providing 30:2 or asynchronous ventilations every 6 seconds, you’re not committing this harmful error (it should also be noted that we teach our EMTs and paramedic to give 1/2 a bag squeeze).

      Your points about positive pressure vs. negative pressure are well taken, but at some point it seems to me you need to blow off CO2. Not to mention, I believe that waveform capnography is very helpful to both monitor the quality of CPR and to help identify ROSC.

      We provide continuous chest compressions for the first 3 minutes of the arrest for the simple reason that we set up the BVM and place the OPA during the first 2 minute cycle after the first shock. Keep in mind, usually the downtime has been a good 10 minutes by the time EMS arrives at the scene (collapse to recognition, recognition to 9-1-1 call, call processing interval, dispatch, reaction time, wheels-up to wheels-down at the curbside of the emergency, curbside of the emergency to patient’s side).

      This is just how my department does it. There is more than one way to skin a cat. However, I am 100% positive that getting a department to perform consistently from crew to crew, shift to shift, day to day, week to week, is the hard part.

      So by all means, debate how your department is going to do it, but pick a way, train that way, and provide ongoing feedback. Otherwise you’ll have different crews and different paramedics handling it dozens of different ways and that is a non-system.

      As a final thought, if you’re stopping for 10 seconds to ventilate twice you’re doing it wrong. That should take no more than 3 seconds. I also would not recommend trying to time artificial ventilations with the downstroke of a chest compression.

  • Dave says:

    Great breakdown of pit crew CPR. I did have a couple comments on application of the LUCAS and the time it takes to put this devise on REAL people. We have used the LUCAS both the first generation and now the LUCAS 2 for years now in my system. We have found through practical trial that 2-4 min of manual CPR is done before the LUCAS is put on for a couple of reasons.
    1- it reduces the time to start immediate compressions when it is procedure to start manual compressions instead of delayed CPR while crew break out the compression devise.
    2- It gives the crew time to get the LUCAS set up, turn on, back plate out and listening for coordinated instructions to make the application as seamless as possible all while manual compressions are being done ( take in consideration our cardiac arrests get at least a 3 person engine crew and a 2 person MICU )

    Last is the LUCAS can be consistantly put on REAL people with only 10 sec. pauses. We have achieved this by making this into a 2 part application.
    First place the back plate under the pt. and then immediatly start manual CPR again. This usally takes less than 5 seconds to do if coordinated well.
    Second when manual CPR is still being done you can clip one side of the LUCAS devise into the back plate the wing of the LUCAS allows you to do this without getting in the way of the person doing CPR.
    Third with the LUCAS already turn on coordinate with the person doing manual CPR to stop and simply flip the other side of the LUCAS over to clip in the other side and press start. The person doing CPR can help guide the other wing into the back plate making this easier. This just takes maybe 1-2 sec. to get this done.

    This has been done in our system with very good results on MANY real cardiac arrests and not just classroom stuff. We download all of our cardiac arrests from our LP15 and can see excactly how long our pauses are during this time.

    Give it a try

    Dave

    • Tom Bouthillet says:

      Dave: This is a topic that I am very interested in. Do you use CODE-STAT? If so, can you demonstrate with data that the application time is less than 10 seconds (last manual compression to first mechanical compression)?

      • Dave says:

        Yes we do use CODE- STAT and have documented stats specificaly on LUCAS application times. I will get the info from my medical director and pass it on.

        • Tom Bouthillet says:

          You guys should consider publishing! Even if it’s a case series (10 consecutive cases or something along those lines). We definitely need research in this area!

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