ACLS Team Roles and Responsibilities
Every resuscitation event must have a designated team leader who directs and coordinates all components of the resuscitation with a central focus on delivering high-quality CPR, while other team members perform specific tasks simultaneously in a "pit crew" fashion to minimize interruptions in chest compressions. 1
Core Team Structure
The ACLS team operates as an integrated unit where multiple tasks are performed concurrently rather than sequentially. The effectiveness of resuscitation depends on clear role delineation and coordinated execution 1, 2.
Team Leader
The team leader's primary responsibility is to organize individual experts into an expert team by:
- Maintaining a hands-off approach - Does not perform chest compressions or other manual tasks 1
- Directing and prioritizing essential activities with focus on CPR quality 1
- Choreographing team activities to minimize compression interruptions 1
- Communicating clearly about impending pauses to enable simultaneous task completion 1
- Monitoring CPR quality metrics: compression fraction >80%, rate 100-120/min, depth ≥2 inches 1, 2
- Identifying and treating reversible causes (H's and T's) 3, 2
Critical pitfall: Team leaders who participate in manual tasks cannot effectively monitor overall resuscitation quality and team coordination 1.
Compressor (Primary and Secondary)
- Delivers high-quality chest compressions: depth ≥2 inches, rate 100-120/min, complete recoil 4, 2
- Minimizes interruptions - hands-off time should be <10 seconds 1
- Switches every 2 minutes or sooner if fatigued to maintain quality 4
- Compression-ventilation ratio: 30:2 for single rescuer, 15:2 for two rescuers in pediatrics, continuous compressions once advanced airway placed 4
Airway Manager
- Provides bag-mask ventilation initially with oxygen 4, 5
- Places advanced airway (endotracheal tube or supraglottic device) without prolonged compression interruptions 5
- Confirms placement using waveform capnography 5
- Delivers ventilations: 1 breath every 6-8 seconds (8-10 breaths/min) after advanced airway placement 5
- Attaches HEPA filter to ventilation devices in infectious disease scenarios 3
Key consideration: The most experienced provider should manage the airway, particularly in difficult airway situations like pregnancy 3.
Monitor/Defibrillator Operator
- Attaches monitor/defibrillator immediately 4
- Identifies rhythm and communicates to team leader 2
- Delivers shocks for VF/pulseless VT with minimal compression pause 2
- Resumes CPR immediately after shock delivery 4
- Monitors for rhythm changes every 2 minutes 4
Medication/IV Access Provider
- Establishes vascular access (IV or IO) 4, 5
- Prepares and administers medications as directed by team leader 4
- Epinephrine dosing:
- Administers antiarrhythmics for refractory VF/pVT:
Recorder/Timekeeper
- Documents all interventions with precise timing 1
- Tracks medication administration (drug, dose, time) 1
- Announces 2-minute intervals for rhythm checks and compressor switches 1
- Records CPR quality metrics when available 1
Team Coordination Principles
Minimizing Compression Interruptions
Prioritize optimization in this order when ETCO₂ <20 mmHg 1:
- Compression fraction (target >80%)
- Compression rate (100-120/min)
- Compression depth (≥2 inches)
- Avoiding leaning
- Avoiding excessive ventilation
Simultaneous Task Performance
Tasks that can be performed during ongoing compressions 1:
- IV/IO access establishment
- Medication preparation and administration
- Advanced airway preparation
- Monitor attachment
- Reversible cause identification
Tasks requiring brief, coordinated pauses 1:
- Rhythm analysis
- Pulse checks (≤10 seconds)
- Defibrillation (minimize to <10 seconds)
Training and Performance
Teams with at least one member completing accredited ACLS training demonstrate higher ROSC rates and improved survival to hospital discharge 6. However, training must emphasize:
- Team-based performance over individual skills 7
- Simulation-based learning with realistic scenarios 6, 8
- Leadership behaviors: setting clear expectations, being decisive, maintaining situational awareness 1
- Multidisciplinary coordination to enhance communication and mutual learning 7
Important caveat: Skills like endotracheal intubation cannot be adequately taught in 2-3 day courses and require supervised clinical practice 7.
Special Circumstances
Pediatric Modifications
- Two-rescuer ratio: 15:2 compressions to ventilations 4
- Compression depth: at least one-third anteroposterior chest diameter 4
- Ventilations prioritized due to asphyxial arrest etiology 3
Pregnancy
- Continuous lateral uterine displacement to relieve aortocaval compression 3
- Perimortem cesarean delivery within 5 minutes if no ROSC 3
- Multidisciplinary team planning with obstetrics, anesthesia, neonatal services 3
COVID-19/Infectious Disease
- All rescuers wear appropriate PPE for aerosol-generating procedures before initiating ventilations 3
- HEPA filters on all ventilation devices 3
- Minimize personnel in room during resuscitation 3
The effectiveness of ACLS teams depends not on the number of providers, but on clear role assignment, coordinated execution, and relentless focus on high-quality CPR with minimal interruptions 1, 2.