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28 JANUARY 2018 | EMSWORLD.com M ore than 400,000 people in the U.S. experience nontraumatic out-of-hospital cardiac arrest (OHCA) every year. 1 The rate of pediatric OHCA is nearly 8 cases per 100,000 person-years—about 1/15th that of adults— and is more frequent in infants compared to children and adolescents. 2 Survival to hospi- tal discharge occurs in approximately 9.5% of adult OHCAs 3 and 6.4%–8.6% of OHCAs in children. 2,4,5 Despite advances in resuscita- tion practices and technology over the last 20 years, survival to hospital discharge has remained stagnant in both populations. 5–7 Factors Associated With Survival Children with a witnessed cardiac arrest or initial shockable rhythm (ventricular tachy- cardia or ventricular fibrillation) are more likely to survive as opposed to those in asys- tole or pulseless electrical activity (PEA). 2,5,8 Furthermore, older children and teenagers are more likely to survive than infants less than 1 year. 2,5 Blunt traumatic cardiac arrest conveys a much poorer prognosis, with only 3.4% surviving to hospital discharge. 9 Studies of bystander CPR have shown mixed results with regard to survival and good neurologic outcomes, 2,4,5,8,10–13 primar- ily related to the witnessed or unwitnessed nature of the onset of cardiac arrest. An EMS time-on-scene of 10–35 minutes, compared to less than 10 minutes (i.e., a "scoop and run" approach), is also associated with improved survival. 14 The American Heart Association (AHA) guidelines for the care of adults and children with OHCA, published in 2010 15 and updated in 2015, 16 emphasize high-quality CPR as a key strategy for resuscitation teams. Not- ing that victims of cardiac arrest still receive variable and suboptimal CPR, 17–20 the AHA provided five critical components of high- quality CPR to help prioritize and improve resuscitative efforts: 1. Minimize interruptions. Maintain a chest compression fraction (CCF; the propor- tion of time that chest compressions are performed during a cardiac arrest) of greater than 80%; 2. Maintain a chest compression rate of 100–120 per minute; 3. Compress to a depth of at least 50 mm in adults and at least one-third the anterior-posterior dimension of the chest in infants and children; 4. Avoid leaning during compressions in order to allow for full chest recoil; and 5. Avoid excessive ventilations and venti- lation volume (less than 12 breaths per minute and no more than visible chest rise, respectively). 21 Many recent studies of EMS systems implementing high-quality CPR, especially with team-focused or "pit crew" models, have obser ved improved sur vival out- comes for OHCA. 22–27 Team-focused and pit crew models are highly choreographed approaches to high-quality CPR emphasiz- ing AHA guidelines. Mounting evidence demonstrates the cor- relation of quality prehospital resuscitation with improved OHCA survival, 23,26,27,29,30 con- trasted with worsened quality and increased variability of CPR during EMS transport. 31–34 Furthermore, obtaining ROSC in the field is one of the strongest predictors of survival. 1 The integration of a highly choreo- graphed pit crew model replaces the vari- ability of the "scoop and run" technique commonly employed in pediatric OHCA with a more structured approach focused on early high-quality CPR in order to maxi- mize the possibility of ROSC and survival. Compliance with the updated AHA guide- lines, most notably the five key components THE PIT CREW MODEL AND PEDIATRIC CARDIAC ARREST Early high-quality CPR may represent a path to better outcomes By Phillip Friesen, DO; Lawrence H. Brown, PhD; Jose Cabanas, MD, MPH, FACEP; Paul Hinchey, MD, MBA, FACEP; and Katherine Remick, MD, FAAP, FACEP, FAEMS