Post-Resuscitation Management

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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 patient
    • 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)
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