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Post Resuscitation Care

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If a patient has a Return of Spontaneous Circulation (ROSC), start Post-Resuscitation Care immediately. The initial PALS process is intended to stabilize a patient during a life-threatening event. Post-Resuscitation Care is meant to optimize ventilation and circulation, preserve organ/tissue function, and maintain recommended blood glucose levels. Below find a systematic approach followed by a post-resuscitation care algorithm to guide you in your treatment.

Respiratory System

  • Chest X-ray to verify ET tube placement
  • Arterial blood gas (ABG) and correct acid/base disturbance
  • Pulse oximetry (continuously monitor)
  • Heart rate and rhythm (continuously monitor)
  • End-tidal CO2 (if the patient is intubated)
  • Maintain adequate oxygenation (saturation between 94% and 99%)
  • Maintain adequate ventilation to achieve PCO2 between 35-45 mm Hg unless otherwise indicated.
  • Intubate if:
    • Oxygen and other interventions do not achieve adequate oxygenation
    • Needed to maintain a patent airway in the child with decreased level of consciousness
    • Ventilation is not possible through non-invasive means (e.g. CPAP)
  • Control pain with analgesics and anxiety with sedatives (e.g. benzodiazepines)

Cardiovascular System

  • Arterial blood gas (ABG) and correct acid/base disturbances
  • Hemoglobin and hematocrit (transfuse or support as needed)
  • Heart rate and rhythm (continuously monitor)
  • Blood pressure (continuously monitor with arterial line)
  • Central venous pressure (CVP)
  • Urine output
  • Chest X-ray
  • 12 lead ECG
  • Consider echocardiography
  • Maintain appropriate intravascular volume
  • Treat hypotension (use vasopressors if needed and titrate BP)
  • Pulse oximetry (continuously monitor)
  • Maintain adequate oxygenation (saturation between 94% and 99%)
  • Correct metabolic abnormalities (chemistry panel)

Neurological System

  • Elevate head of bed if blood pressure can sustain cerebral perfusion
  • Temperature
    • Avoid hyperthermia and treat fever aggressively
    • Do not re-warm hypothermic cardiac arrest patient unless hypothermia is interfering with cardiovascular function
    • Treat hypothermia complications as they arise
  • Blood glucose
    • Treat hypo/hyperglycemia (hypoglycemia defined as less than or equal to 60 mg/dL)
  • Monitor and treat seizures
    • Seizure medications
    • Remove metabolic/toxic causes
  • Blood pressure (continuously monitor with arterial line)
  • Maintain cardiac output and cerebral perfusion
  • Normoventilation unless temporizing due to intracranial swelling
  • Frequent neurological exams
  • Consider CT and/or EEG
  • Dilated unresponsive pupils, hypertension, bradycardia, respiratory irregularities, or apnea may indicate cerebral herniation.

Renal System

  • Monitor urine output
    • Infants and small children: > 1 ml/kg/hr
    • Larger children: > 30ml/hr
    • Exceedingly high urine output could indicate neurological or renal problem (diabetes insipidus)
  • Routine blood chemistries
  • Arterial blood gas (ABG) and correct acid/base disturbances
  • Urinalysis (when indicated)
  • Maintain cardiac output and renal perfusion
  • Consider the effect of medications on renal tissue (nephrotoxicity)
  • Consider urine output in the context of fluid resuscitation
  • Toxins can sometimes be removed with urgent/emergent hemodialysis when antidotes fail or are not available

Gastrointestinal System

  • Monitor NG/OG tube for patency and residuals
  • Perform a thorough abdominal exam
    • Tense abdomen may indicate bowel perforation or hemorrhage
  • Consider abdominal ultrasound and/or abdominal CT
  • Routine blood chemistries including liver panel
  • Arterial blood gas (ABG) and correct acid/base disturbances
  • Be vigilant for bleeding into the bowel, especially after hemorrhagic shock

Hematological System

  • Monitor complete blood count and coagulation panel
  • Transfuse (as needed)
    • Correct thrombocytopenia
    • Fresh frozen plasma is to replenish clotting factors
    • Consider calcium chloride or gluconate if massive transfusion required
  • Correct metabolic abnormalities (chemistry panel), especially after transfusion
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