Pit Crew CPR
January 23, 2019
Author: Kuo Downing-Reese
When you think about cardiac arrest, does NASCAR immediately come to mind? For most, the answer is probably no. You are thinking about everything that needs to be done. At times, this list can be daunting, especially when you realize that it all should be done in about two minutes. So why the question about NASCAR? In 2015, the American Heart Association (AHA) released its newest set of guidelines for CPR. In the update, they described a theory called pit crew CPR.
Pit crew CPR is built on the premise that the first responders will have preassigned roles and that communication will be smooth. Here are the six roles that are outlined:
- Team Leader. Ideally, this person is hands off and orchestrates the resuscitation. They should be knowledgeable in the algorithms set forth by the AHA. They also need to be able to properly identify cardiac rhythms and be well versed in the medications.
- Compressions. Each compression must be hard, fast and deep. A rate between 100-120 bpm is the goal. The person performing compressions must also be aware of full recoil for compressions to be effective.
- Defibrillation. The person responsible for defibrillation may or may not fully understand the cardiac rhythms, but they do need to know how to correctly place the defibrillation pads, charge and safely deploy the defibrillation. The compressor and the defibrillation positions should switch roles every two minutes in order to keep providers from getting fatigued.
- Ventilation. This role can either be provided by using basic or advanced airways adjuncts. Ideally, this role is being done without any further interruptions of compressions. If a provider cannot intubate while compressions are being done, then the use of a blind insertion supraglotic airway such as a KING airway should be implemented.
- Intravenous (IV) or intraosseous (IO) and medications. The use of either IV or IO is acceptable and should be done between the first and second rhythm check. This person will also administer medications, preferably right after a rhythm check and defibrillation so the medication is circulated for the full two-minute cycle.
- Documentation. This person will document the events of the cardiac arrest.
When all these roles are performed efficiently and communication is smoothly, studies show that patients have a much higher rate of survivability with favorable neurological outcomes.1
In the Field
While these six different roles are great, when available, what should you do if only you and your partner are on scene? First, confirm cardiac arrest. Next, request more resources. In most areas a cardiac arrest call with get a fire and police response, as well as the EMS response.
Depending on how you staff your ambulance, you and your partner may both be advanced providers or there may only be one. If both you and your partner can fulfill all the roles described above, then you can split the responsibilities as needed. If only one of you is an advanced provider, I have found that the best approach is for them to position themselves at the head of the patient.
If I am the advanced provider, I will place my monitor to my left, my drug box to my right and my airway kit just slightly behind me. My partner will know this setup before we ever arrive on scene. Their role is to place the defibrillation pads and begin compressions as soon as we confirm we have a pulseless, apneic patient. From the patient’s head, I can determine our first rhythm, deliver a shock, and then move to IO insertion into the right humeral head. Normally I prefer to get a large bore IV but with minimal providers, the use of IO is both quick and efficient.3 Placement in the right humeral head has been found to deliver higher rates of infusion and closer proximity to the central venous system making placement in the humeral head preferred to tibial.2 From this set up, it is possible to give medications without needing to move. At the head, I am also in a good position to place either an endotracheal or King airway and secure waveform capnography.
By that time, secondary providers should be arriving, and my partner can rest while someone else takes over compression. To record events, we would use the monitor, which has a function to mark events and keep time. The monitor also has a CPR feedback device that can be used to monitor compressions to ensure high quality CPR is being delivered.
While you may not always have six people available to respond to a cardiac arrest call, pit crew CPR is still possible. This approach will help ensure high-quality CPR and will hopefully mean higher rates of ROSC (return of spontaneous circulation). On your next cardiac arrest patient, consider responding with “NASCAR” pit crew resuscitation.
- Hopkins, C.L. (2016). Implementation of Pit Crew Approach and Cardiopulmonary Resuscitation Metrics for Out‐of‐Hospital Cardiac Arrest Improves Patient Survival and Neurological Outcome. Journal of the American Heart Association. 2016;5:e002892. Retrieved from https://www.ahajournals.org/doi/10.1161/JAHA.115.002892
- Wesley, K. (2016). Pit Crew Approach to CPR has Higher Patient Survival Rates. Journal of Emergency Medical Services. 41(8). Retrieved from https://www.jems.com/articles/print/volume-41/issue-8/departments-columns/street-science/pit-crew-approach-to-cpr-has-higher-patient-survival-rates.html
- Anson, J.A. M.D. (2014). Vascular Access in Resuscitation: Is There a Role for the Intraosseous Route?. Anesthesiology: The Journal of the American Society of Anesthesiologists, Inc. Vol.120, 1015-1031. doi:10.1097/ALN.0000000000000140. Retrieved from http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1917840