Pit Crew CPR

If Engine/Ladder Arrives First 

• Ensure 360^o access around patient and consider moving patient before initiating CPR. 

• The crew will always maintain a triangular configuration around the patient and occupy positions 1, 2, and 3.  
• A member of the crew will occupy position number 1. This crewmember will check for a pulse (10 seconds or less) and if the patient is in cardiac arrest, they will immediately begin High Quality chest compressions at a rate of 110 per minute. The goal is 220 compressions in two mins. There will be a 10:1 ratio of compressions to ventilations once the BVM is ready. They will switch off compressions with provider 2. 
• The second crewmember on the pumper will occupy position 2, apply defibrillation pads, and operate the AED/Monitor.  Ensure compressions continue during AED charging and immediately resume compressions after shock without pulse check or rhythm analysis.  
• The final provider will move to position three on arrival and place an I-gel airway on all patients. Compressions should not be stopped to secure the airway. The paramedic will then ventilate the patient after every 10^th compression in a manner that is asynchronous with chest compressions. Provider 3 can assess for sufficient chest compressions by performing a pulse check (carotid/brachial). 
• The crewmembers in positions 1 and 2 will take turns doing 2 minutes of compressions (110 compressions per minute).  
• During Provider 1’s rest cycle, they can consider IV/IO access and initiate drug therapy. This can be deferred until more help arrives. 

When the Ambulance Arrives after the Engine/Ladder 

• When the ambulance arrives, one paramedic will assume position 4 and obtain vascular access. An intraosseous line in the proximal humerus is preferred unless there are any contraindications, followed by IV and then tibial IO. This medic will then oversee giving medications. They can also obtain history from the family, contact the hospital, or go for equipment if necessary.  
• The other paramedic on the ambulance will assume position 5 and exchange the AED for the monitor. The goal is to ensure continuous waveform capnography, monitor CPR feedback to correct chest compressions, and defibrillate as needed during pulse checks.  
• Approximately 15 seconds prior to rhythm check, the monitor should be precharged. If a shockable rhythm is noted, an immediate shock should be delivered. After the shock or if no shock is advised and charged is dumped, the provider (1 or 2) coming off a rest cycle will do 2 minutes of chest compressions.  
• A carotid pulse needs to be identified during compressions to assist in pulse checks. 
• Provider 5 will also determine the intubation plan for the patient. If needed, they will convert the I-gel airway to an endotracheal tube. This will be in a controlled fashion with a full intubation setup. Compressions will not be stopped for the intubation attempt. This step can be deferred until after AutoPulse/LUCAS is placed on patient.