PALS Provider: Course

Stabilization and Post-Resuscitation Management

Once a pediatric patient achieves Return of Spontaneous Circulation (ROSC) after cardiac arrest, the clinical focus shifts from resuscitation to stabilization—preventing recurrence, supporting organ function, and protecting the brain. This phase is critical to long-term survival and neurological recovery.

Key Goals of Post-Resuscitation Care

  • Optimize hemodynamics and oxygenation
  • Prevent secondary brain injury
  • Monitor for and treat organ dysfunction
  • Identify and address the underlying cause of arrest

1. Immediate Priorities After ROSC

  • Assess and secure Airway, Breathing, Circulation (ABCs)
  • Initiate continuous cardiac monitoring
  • Perform frequent neurological assessments
  • Correct reversible causes (H’s and T’s)

Prevent Re-Arrest: Treat hypoxia, acidosis, and electrolyte imbalances. Use inotropes for poor perfusion and monitor for shock or seizures.

2. Hemodynamic Support

Target MAP:

  • Neonates: >40 mmHg
  • Infants/Children: >50 mmHg
  • Adolescents: >60 mmHg

Fluid Resuscitation: 10–20 mL/kg isotonic crystalloids IV over 10–20 minutes. Repeat cautiously if needed.

Vasoactive Medications:

  • Hypotensive shock: Epinephrine or Dopamine
  • Cardiogenic shock: Epinephrine or Dobutamine
  • Septic shock: Norepinephrine (cold), Epinephrine (warm), Vasopressin (if refractory)

3. Respiratory Support

  • Target SpO₂: 94–99% (avoid hyperoxia)
  • Target PCO₂: 35–45 mmHg
  • Use capnography to monitor ETCO₂ if intubated

Both hypo- and hypercapnia can worsen cerebral outcomes—ventilate appropriately.

4. Temperature Control

  • Maintain normothermia (36–37.5°C)
  • Consider hypothermia (32–34°C) in comatose patients
  • Avoid hyperthermia at all costs
  • If cooling, maintain for 24–48 hrs, rewarm slowly at 0.25°C/hour

5. Neurological Monitoring & Seizure Control

  • Use Glasgow Coma Scale (or Pediatric version)
  • Continuous EEG for patients with altered mental status or suspected seizures
  • Seizure treatment: Lorazepam 0.1 mg/kg IV → then fosphenytoin or levetiracetam if needed

6. Lab Monitoring & Organ Function

  • ABG: Assess pH, CO₂
  • Lactate: Perfusion marker
  • Electrolytes: Sodium, potassium, calcium, magnesium
  • Glucose: Maintain >70 mg/dL
  • Liver/kidney function: Track end-organ status

7. Reversible Causes (H’s and T’s)

  • H’s: Hypoxia, Hypovolemia, Acidosis, Hypo-/Hyperkalemia, Hypoglycemia, Hypothermia
  • T’s: Tension pneumothorax, Tamponade, Toxins, Thrombosis (PE/MI)

Treat these causes early to prevent re-arrest.

8. Summary Checklist

  • Hemodynamics: Fluids and vasoactives (Epi, Dopamine)
  • Oxygenation: SpO₂ 94–99%, normocapnia
  • Temperature: Prevent hyperthermia; consider TTM
  • Neuro: Frequent exams, seizure monitoring
  • Labs: ABG, lactate, electrolytes, glucose
  • Causes: Fix the H’s and T’s

9. Escalation of Care

  • ECMO: Consider for refractory cardiogenic shock or arrest
  • Neuroprognostication: Evaluate at 72 hours post-arrest if no response

10. Final Takeaway

Post-resuscitation care is just as vital as the initial resuscitation effort. Balancing oxygenation, perfusion, temperature, and neurological protection gives the child the best chance for meaningful recovery.