Post-Resuscitation Management

Post-resuscitation care must be started immediately if a person has a return of spontaneous circulation (ROSC). During a life-threatening event, the initial PALS process is intended to stabilize a child or an infant. Maintaining recommended blood glucose levels, preserving organ/tissue function, and optimizing ventilation and circulation are some of the goals of post-resuscitation care. To guide you in your treatment, a post-resuscitation care algorithm and a systematic approach are illustrated below.

Respiratory System

• Verify ET tube placement with chest X-ray
• Correct acid/base disturbance and arterial blood glass (ABG)
• Continuously monitor pulse oximetry
• Continuously monitor heart rate and rhythm
• If the person is intubated, end-tidal CO₂
• Maintain adequate oxygenation with a saturation between 94% and 99%
• Unless otherwise indicated, maintain adequate ventilation to achieve PCO₂ between 35 to 45 mm Hg
• Only intubate if:
  • Adequate oxygenation is not achieved with oxygen or other interventions
  • The child with decreased level of consciousness needs a patent airway maintained
  • Non-invasive means are not possible for ventilation, e.g. continuous positive airway pressure (CPAP)
• Control anxiety with sedatives (e.g., benzodiazepines) and pain with analgesics

Cardiovascular System

• Correct acid/base disturbances and arterial blood gas (ABG)
• Transfuse or support as needed the hemoglobin and hematocrit
• Continuously monitor blood pressure with arterial line
• Continuously monitor heart rate and rhythm
• Central venous pressure (CVP)
• Urine output
• Chest X-ray
• 12-lead ECG
• Consider echocardiography
• Maintain appropriate intravascular volume
• Treat hypotension, use vasopressors when necessary and titrate blood pressure
• Continuously monitor pulse oximetry
• Maintain adequate oxygenation with a saturation between 94% and 99%
• Correct metabolic abnormalities

Neurological System

• If blood pressure can sustain cerebral perfusion, elevate head of bed
• Monitor temperature
  • Treat fever aggressively; avoid hyperthermia
  • Unless hypothermia is interfering with cardiovascular function, do not re-warm hypothermic cardiac arrest victim
  • Treat hypothermia complications as they arise
• Address blood glucose
  • Treat hypo-/hyperglycemia (hypoglycemia is defined as less than or equal to 60 mg/dL)
• Monitor and treat seizures
  • Seizure medications
  • Remove metabolic/toxic causes
• Continuously monitor blood pressure with arterial line
• Maintain cardiac output and cerebral perfusion
• Use normoventilation unless temporizing due to intracranial swelling
• Perform frequent neurological exams
• Consider CT and/or EEG (electroencephalogram)
• Cerebral herniation may be indicated by respiratory irregularities, bradycardia, hypertension, dilated unresponsive pupils, or apnea

Renal System

• Monitor urine output
  • Infants and small children: less than 1 mL/kg an hour
  • Larger children: less than 30 mL an hour
  • Neurological or renal problem (diabetes insipidus) could be indicated by exceedingly high urine output
• Perform routine blood chemistries
• Correct acid/base disturbances and arterial blood gas (ABG)
• When indicated, perform urinalysis
• Maintain renal perfusion and cardiac output
• Consider how renal tissue is affected by medications (nephrotoxicity)
• Consider urine output in the context of fluid resuscitation
• When antidotes fail or are not available, toxins can sometimes be removed with urgent/emergent hemodialysis

Gastrointestinal System

• For patency and residuals, monitor nasogastric (NG)/orogastric (OG) tube
• Perform a thorough abdominal exam
• Bowel perforation or hemorrhage may be indicated by tense abdomen
• Consider abdominal CT and/or abdominal ultrasound
• Perform routine blood chemistries including liver panel
• Correct acid/base disturbances and arterial blood gas (ABG)
• Especially after hemorrhagic shock, be vigilant for bleeding into the bowel

Hematological System

• Monitor coagulation pane and complete blood count
• Transfuse as needed
  • Correct thrombocytopenia
  • Replenish clotting factors with fresh frozen plasma
  • If massive transfusion is required, consider calcium chloride or gluconate
• Especially after transfusion, correct metabolic abnormalities (chemistry panel)