The Pit Crew Model and Pediatric Cardiac Arrest

More 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 hospital discharge occurs in approximately 9.5% of adult OHCAs³ and 6.4%–8.6% of OHCAs in children.^2,4,5 Despite advances in resuscitation 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 tachycardia or ventricular fibrillation) are more likely to survive as opposed to those in asystole 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} primarily 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 2010¹⁵ and updated in 2015,¹⁶ emphasize high-quality CPR as a key strategy for resuscitation teams. Noting 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 proportion 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 ventilation 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 observed improved survival outcomes for OHCA.^22–27 Team-focused and pit crew models are highly choreographed approaches to high-quality CPR emphasizing AHA guidelines. 

Mounting evidence demonstrates the correlation of quality prehospital resuscitation with improved OHCA survival,^{23,26,27,29,30} contrasted 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 choreographed pit crew model replaces the variability 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 maximize the possibility of ROSC and survival.

Compliance with the updated AHA guidelines, most notably the five key components related to CPR quality, is critical to this success.

A Pit Crew Model for Pediatric OHCA

The Austin-Travis County EMS system currently covers an urban/suburban population of more than 1.14 million people, with more than 120,000 scene responses per year.²⁸ In January 2011 leaders undertook a quality initiative to improve OHCA survival, specifically targeting implementation of high-quality CPR with a pit crew model of resuscitation. A retrospective case review was performed to characterize all traumatic and nontraumatic pediatric out-of-hospital cardiac arrests from January 2011 to March 2013 that occurred in the system after implementation of its pit crew approach.

Out of 53 pediatric OHCAs with outcome data during the study period, 18 (34%; 95% CI, 22%–48%) patients achieved ROSC in the field, and 9 (17%; 95% CI, 8%–30%) survived to hospital discharge. Survivors were more likely to have had witnessed arrests (p=0.016) and less likely to present in asystole (p<0.001). Patient age did not differ for survivors and nonsurvivors (median [IQR] 7 [3–7] years vs. 1 [0–9] years; p=0.122).

There were also no significant associations between cardiac arrest etiologies, performance of bystander CPR, or presentation with a shockable rhythm and survival to hospital discharge. Asystole was the most common presenting rhythm (59%), and shockable rhythms were rare (9%). Presumed etiologies for pediatric cardiac arrests across the entire study were most commonly recorded as respiratory (30%) or other/unknown (32%), with cardiac (17%) and traumatic (13%) etiologies making up the balance.

Future of Pediatric Pit Crew Resuscitation

In developing the first published evaluation of outcomes in pediatric out-of-hospital cardiac arrest following pit crew resuscitation, we obtained a 17% overall survival rate—markedly higher than previously reported outcomes for pediatric OHCA patients.^2,4,5 Albeit from a small and single-system study, these results underscore the benefit and consideration of moving away from a “scoop and run” approach to a focus on early, high-quality CPR for children. Larger multisystem studies evaluating the pit crew approach to pediatric OHCA are needed to further validate this approach.

References

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2. Atkins DL, Everson-Stewart S, Sears GK, et al. Resuscitation Outcomes Consortium Investigators. Epidemiology and outcomes from out-of-hospital cardiac arrest in children. Circulation, 2009 Mar 24; 119(11): 1,484–91.

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8. Donoghue AJ, Nadkarni V, Berg RA, et al. CanAm Pediatric Cardiac Arrest Investigators. Out-of-hospital pediatric cardiac arrest: An epidemiologic review and assessment of current knowledge. Ann Emerg Med, 2005 Dec; 46(6): 512–22.

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24. Hinchey PR, Myers JB, Lewis R, et al. Capital County Research Consortium. Improved out-of-hospital cardiac arrest survival after the sequential implementation of 2005 AHA guidelines for compressions, ventilations, and induced hypothermia: The Wake county experience. Ann Emerg Med, 2010; 56: 348–57.

25. Vadeboncoeur T, Stolz U, Panchal A, et al. Chest compression depth and survival in out-of-hospital cardiac arrest. Resuscitation, 2014; 85: 182–6.

26. Hopkins CL, Burk C, Moser S, et al. Implementation of pit crew approach and cardiopulmonary resuscitation metrics for out-of-hospital cardiac arrest improves patient survival and neurological outcome. J Am Heart Assoc, 2016 Jan 11; 5: 1–10.

27. Pearson DA, Darrell Nelson R, Monk L, et al. Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: Results from a statewide quality improvement initiative. Resuscitation, 2016 Aug; 105: 165–72.

28. Austin-Travis County EMS, www.austintexas.gov/department/ems. 

29. Wik L, Olsen JA, Persse D, et al. Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation, 2014 Jun; 85(6): 741–8.

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31. Olasveengen TM, Wik L, Steen P. Quality of cardiopulmonary resuscitation before and during transport in out-of-hospital cardiac arrest. Resuscitation, 2008 Feb; 76(2): 185–90.

32. Fox J, Fiechter R, Gerstl P. Mechanical versus manual chest compression CPR under ground ambulance transport conditions. Acute Card Care, 2013 Mar; 15(1): 1–6.

33. Roosa JR, Vadeboncoeur TF, Dommer PB, et al. CPR variability during ground ambulance transport of patients in cardiac arrest. Resuscitation, 2013; 84(5): 592–5.

34. Lyon RM, Crawford A, Crookston C, Short S, Clegg GR. The combined use of mechanical CPR and a carry sheet to maintain quality resuscitation in out-of-hospital cardiac arrest patients during extrication and transport. Resuscitation, 2015; 93: 102–6.

Phillip Friesen, DO, is a pediatric emergency medicine faculty member at Dell Children’s Medical Center, Austin, Tex.

Lawrence H. Brown, PhD, is associate professor and director of research education for the emergency medicine program at Dell Medical School, University of Texas.

Jose Cabanas, MD, MPH, FACEP, is medical director for Wake County EMS in Raleigh, N.C.

Paul Hinchey, MD, MBA, FACEP, is assistant medical director for Wake County EMS.

Katherine Remick, MD, FAAP, FACEP, FAEMS, is medical director for the San Marcos Hays County EMS system in Texas.