Stayin’ alive: The 2010 Heart and Stroke Foundation of Canada/American Heart Association resuscitation guidelines for newborns and older children

Abstract

Five years have transpired since the most recent set of paediatric and neonatal resuscitation guidelines were jointly released by the Heart and Stroke Foundation of Canada (HSFC) and the American Heart Association. The recent publication of the 2010 resuscitation guidelines (1–3) prompts the following questions: What process led to the creation of the guidelines? What is new since 2005? What is our role in implementation? Guideline development has evolved from using consensus of experts, to the use of an evidence-based approach. Starting in 2000, the International Liaison Committee on Resuscitation (ILCOR), consisting of resuscitation councils from around the world (including the HSFC), has conducted regular systematic reviews of the resuscitation literature. These reviews resulted in the Consensus on Science and Treatment Recommendations (CoSTR). After the release of ILCOR’s 2005 CoSTR document, the paediatric and neonatal task forces reconvened, with international (including Canadian) representation. Each task force identified key questions requiring evidence evaluation, and assigned each question to two or more international resuscitation experts. After a rigorous literature search, relevant articles were independently identified, analyzed and graded by each worksheet author. With the assistance of an evidence evaluation expert, the scientific information surrounding a specific question was summarized and treatment recommendations were drafted based on this summary. The worksheet summaries (without treatment recommendations) were made available to the wider scientific community through the ILCOR website. Each worksheet author then presented his/her findings one final time to the paediatric or neonatal task forces, who debated and finalized the CoSTR statements (published in October 2010 [4,5]). Since that time, regional resuscitation councils (such as the HSFC and American Heart Association) have released their own resuscitation guidelines that have contextualized the CoSTR documents for their respective health care systems. A significant challenge for the world’s paediatric and neonatal resuscitation community continues to be the paucity of high-quality studies in the basic science, clinical and educational domains. Many resuscitation science recommendations are based on extrapolation from adult (human) studies or even animal data, whereas educational science largely consists of low-level studies of learner outcomes rather than patient outcomes. There is a pressing need for further study regarding how best to translate resuscitation science into practice, and how best to improve knowledge acquisition and retention by both lay rescuers and health care professionals over time. Studies are needed to compare traditional instructor-led courses with newer innovative approaches to teaching including Internet- and computer-based training, and low- or high-fidelity simulation. The rapid attrition of cognitive and technical skills within months of initial instruction suggests that we need to consider other approaches to continuing education, potentially including more frequent refresher courses, training sessions or simulations. The introduction of simulation and debriefing to neonatal resuscitation training will result in substantial changes to Neonatal Resuscitation Program (NRP) courses, presenting new challenges for our instructors and learners. These new methodologies will help us recognize the importance of teamwork competencies, and individual knowledge, skills and behaviours. Fortunately, the clinical science recommendations reinforce and build on practices introduced to Canada in 2006 (6), and will require relatively minor modifications. Outside the newborn population, clearer, simpler and more consistent messaging to the public regarding how to provide cardiopulmonary resuscitation (CPR) to individuals of all ages will hopefully ensure that bystanders act promptly, in contrast to the majority of out-of-hospital cardiac arrests in Canada, where no intervention is provided by lay rescuers. Starting the first cycle of CPR with chest compressions (chest compressions, airway, breathing), as opposed to the traditional order (airway, breathing, chest compressions) will ensure that rescuers immediately ‘do something (ie, at least chest compressions) as opposed to doing nothing’ for all cardiac arrest victims. This will maximize coronary perfusion and delay the provision of rescue breaths by only a few seconds. The challenge for paediatric and neonatal health care providers is to recognize our collective role and responsibility in optimizing resuscitative care for Canada’s infants and children. Although maintaining up-to-date CPR certification and/or NRP registration is an essential first step, our role extends to advocating CPR education for our own children and families, and getting the “stayin’ alive” message out to the public through our patients, their families and the community. It is time for us, as paediatricians, to approach paediatric cardiac arrest as a preventable disease, in the same way that we successfully advanced seatbelt and bicycle helmet education programs. Similarly, perinatal teams should view newborn compromise as predictable in many circumstances and, therefore, assess risk and prepare for resuscitation before every delivery. Finally, it is incumbent on us to cultivate resuscitation-based scientific research to fill the knowledge gaps in basic, clinical and educational science, and inform future CoSTR cycles.