Here is a description of Hilton Head Island Fire Rescue’s Pit Crew CPR process in bullet point form. It may help to think of it as a 4-phase process.
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 cardiac monitor / defibrillator and select the cardiac arrest pick list
- 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 “hover” to indicate they are clear
- Push the shock button
- Resume immediate post-shock compressions
Phase 2: First 2-minute cycle after the first shock
- Post-shock compressions should be ongoing
- Deploy and test the suction unit
- Assemble the BVM
- Attach capnography between mask and bag
- Attach capnography circuit to the monitor
- Attach BVM to oxygen
- Insert an OPA
- Switch to 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)
- 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 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
Note: We are no longer using rapid infusion of cold saline.
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 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.