STABILIZATION AND POST-RESUSCITATION MANAGEMENT (PALS GUIDELINES)
Once a pediatric patient achieves Return of Spontaneous Circulation (ROSC) after cardiac arrest, the focus shifts to preventing recurrence, stabilizing organ function, and optimizing long-term neurological outcomes.
Key Goals of Post-Resuscitation Care:
Optimize hemodynamics and oxygenation. Prevent secondary brain injury. Monitor for and treat organ dysfunction. Identify and treat the underlying cause of arrest.
IMMEDIATE PRIORITIES AFTER ROSC
Assess Airway, Breathing, Circulation (ABCs) Continuous cardiac monitoring to detect arrhythmias. Frequent neurologic exams to assess brain function. Identify and treat the cause of arrest (H’s & T’s).
Prevent Recurrent Arrest:
- Correct hypoxia, acidosis, electrolyte imbalances.
- Provide inotropes if perfusion is poor.
- Monitor closely for seizures or shock.
HEMODYNAMIC SUPPORT: OPTIMIZING PERFUSION
Goal: Maintain adequate blood pressure and organ perfusion
Blood Pressure Targets (Mean Arterial Pressure – MAP):
- Neonates: MAP >40 mmHg
- Infants/Children: MAP >50 mmHg
- Adolescents: MAP >60 mmHg
Fluid Resuscitation (If Hypotensive):
- Isotonic crystalloids (NS or LR) 10-20 mL/kg IV over 10-20 min.
- Repeat as needed, but avoid fluid overload.
Vasoactive Support (If Poor Perfusion Persists):
| Condition | First-Line Vasopressor | Alternative Therapy |
|---|---|---|
| Hypotensive Shock | Epinephrine or Dopamine | Norepinephrine |
| Cardiogenic Shock | Epinephrine or Dobutamine | Milrinone |
| Septic Shock | Norepinephrine (cold shock), Epinephrine (warm shock) | Vasopressin (if refractory) |
If fluid-resistant hypotension persists, start vasoactive medications EARLY!
RESPIRATORY SUPPORT: OPTIMIZING OXYGENATION & VENTILATION
Avoid Hyperoxia:
- Target SpO₂: 94-99% (use lowest FiO₂ to maintain oxygenation).
- Hyperoxia (>100% SpO₂) increases oxidative stress and brain injury.
Avoid Hypocapnia or Hypercapnia:
- Target PCO₂: 35-45 mmHg (normocapnia).
- Hypocapnia (PCO₂ <35) → Causes cerebral vasoconstriction and worsens brain ischemia.
- Hypercapnia (PCO₂ >45) → Increases acidosis and worsens hemodynamics.
If intubated, use capnography to monitor end-tidal CO₂ (ETCO₂) and avoid over-ventilation.
TEMPERATURE CONTROL: TARGETED TEMPERATURE MANAGEMENT (TTM)
Goal: Prevent hyperthermia and consider cooling for neuroprotection
Maintain normothermia (36-37.5°C) or consider therapeutic hypothermia (32-34°C) in select cases. Hyperthermia (>38°C) worsens neurological injury—use cooling blankets if needed. If cooling is initiated, maintain for 24-48 hours, then rewarm slowly (0.25°C/hr).
TTM is especially beneficial for comatose pediatric patients post-arrest.
NEUROLOGICAL MONITORING & SEIZURE MANAGEMENT
Frequent Neurological Exams:
- Assess for responsiveness, pupil reaction, and motor responses.
- Use Glasgow Coma Scale (GCS) or Pediatric Coma Scale.
Continuous EEG Monitoring:
- High risk of seizures post-arrest (often non-convulsive).
- Consider EEG if unexplained neurological deterioration occurs.
Seizure Management:
- First-line: Benzodiazepines (Lorazepam 0.1 mg/kg IV)
- If persistent: Fosphenytoin, Levetiracetam, or Phenobarbital.
Seizures post-arrest worsen brain injury—treat aggressively!
MONITORING & LAB ASSESSMENT
Frequent Monitoring (ICU Setting):
- Vital signs (HR, BP, SpO₂, ETCO₂).
- Continuous cardiac monitoring.
- Neurological assessments (GCS, pupil reactivity).
Laboratory Tests:
- Arterial Blood Gas (ABG): Check for acidosis, PCO₂ levels.
- Serum Lactate: Indicator of perfusion status.
- Electrolytes: Monitor Na⁺, K⁺, Ca²⁺, Mg²⁺ (correct imbalances).
- Glucose: Maintain blood glucose >70 mg/dL, treat hypoglycemia.
- Liver/Kidney Function: Assess for multi-organ dysfunction.
Frequent labs are critical to track recovery and detect complications early!
IDENTIFY & TREAT UNDERLYING CAUSE (H’s & T’s)
Prevent recurrence by correcting the cause of arrest!
The H’s (Common Metabolic Causes) Hypoxia → Optimize oxygenation, ventilation. Hypovolemia → Fluid resuscitation (cautious in cardiogenic shock). Hydrogen ion excess (Acidosis) → Correct underlying cause, bicarbonate if severe. Hyperkalemia/Hypokalemia → Electrolyte correction. Hypoglycemia → Give dextrose (D10, D25). Hypothermia → Rewarm patient if temp <35°C.
The T’s (Cardiac & Trauma Causes) Tension pneumothorax → Needle decompression. Tamponade (Cardiac) → Pericardiocentesis. Toxins (Drug overdose, poisoning) → Administer antidotes. Thrombosis (Pulmonary or Coronary) → Consider thrombolysis or ECMO if needed.
Identifying and treating the reversible cause is crucial for preventing another arrest!
SUMMARY: PEDIATRIC POST-RESUSCITATION CARE CHECKLIST
| Category | Key Actions |
|---|---|
| Hemodynamic Support | Maintain BP with fluids & inotropes (Epinephrine, Dopamine) |
| Respiratory Support | Target SpO₂ 94-99%, PCO₂ 35-45 mmHg |
| Temperature Control | Prevent hyperthermia, consider TTM (32-34°C) |
| Neurological Monitoring | Continuous EEG if comatose, treat seizures |
| Frequent Labs & Imaging | ABG, lactate, electrolytes, glucose, organ function tests |
| Identify & Treat Causes | Correct H’s & T’s to prevent recurrence |
WHEN TO ESCALATE TO ECMO OR ADVANCED SUPPORT?
Consider ECMO (Extracorporeal Membrane Oxygenation) if:
- Severe cardiogenic shock unresponsive to inotropes.
- Refractory cardiac arrest despite CPR and epinephrine.
- Massive pulmonary embolism or severe myocarditis.
Consider Neuroprognostication if:
- No purposeful movement or brainstem reflexes after 72 hours.
- Persistent seizures despite treatment.
FINAL TAKEAWAYS
Post-resuscitation care is crucial for survival and neurological recovery. Hemodynamic and respiratory support should be carefully balanced. Prevent secondary brain injury with oxygen, temperature, and seizure control. Early detection and treatment of the underlying cause prevent recurrence.
Takeaway: Post-resuscitation stabilization is just as important as the initial resuscitation—proper management in this phase improves long-term outcomes!