Post Resuscitation Management

Mortality rates after pediatric cardiac arrest remain high after initial resuscitation and a return of spontaneous circulation. Several factors must be addressed to optimize survival and to prevent subsequent deterioration and/or organ dysfunction and neurologic sequelae. [1][2] Priorities post-resuscitation include ongoing assessment of the resuscitation and stabilization process, determining and managing the etiology of the arrest, neuroprotection to maintain and or minimize brain injury, and preventing decompensation while managing the patient in the emergency department setting, and/or while transporting to a high level of care (pediatric intensive care unit). After a return of spontaneous circulation further stabilization and diagnostic assessments are required. A post-arrest reevaluation includes assessing the adequacy of pulses, both central and peripheral, capillary refill, blood pressure, adequacy of oxygenation and ventilation. This should include continuous cardiac monitoring including pulse oximetry and end-tidal carbon dioxide (CO2) measurements. Perfusion is often compromised post-arrest, and additional fluid boluses and inotropic agents may be required. Dopamine is often helpful to help stabilize blood pressure and improve renal flow. Dobutamine is a good agent for patients in need of a chronotropic agent and does not increase afterload. Post-arrest patients may be hypotensive. Continuous epinephrine infusions are preferred for several reasons. Epinephrine causes peripheral vasoconstriction which helps to improve blood pressure. Epinephrine is also a potent inotropic and chronotropic agent. If the etiology of the cardiac arrest was an arrhythmia, then loading the patient with appropriate antiarrhythmic agents such as lidocaine or amiodarone may be needed. Constant cardiac monitoring is needed to evaluate for the recurrence of worrisome rhythms. Addressing factors that may lead to arrhythmia must also be addressed for example hypoxia, acidosis, hypo/hyperkalemia.