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Every healthcare system should implement a comprehensive and multi-disciplinary system of care in a universal and consistent manner for the treatment of post-cardiac arrest patients in order to assure the very best outcomes. When a patient has a return of spontaneous circulation after a cardiac arrest, otherwise known as ROSC, there are two phases of care that are so important to address. The first is a continuation of ALS, and the second will be to focus on the neurologic and core temperature management, in order to protect the patient's core components as they recover from such a traumatic event. Now let's take a closer look at the first phase. In this phase, we will continue to provide advanced life support for immediate, life-threatening conditions and focus on the ABCs. Because respiratory complications and hemodynamic instability are the primary early causes of mortality after ROSC, it's vital to provide optimum oxygenation and ventilation. The goal is to keep an SpO2 of greater than 94%. Diagnostic tools need to be used in order to optimize care, such as monitoring end-tidal CO2 with capnography, assessing arterial blood gas, and obtaining a chest x-ray to confirm proper endotracheal tube position in the mid-trachea. In addition, perfusion must be stabilized and cardiopulmonary function needs to be monitored. The goal is to treat any persistent shock. This may require fluid boluses of 20 ml/kg or medications like Epinephrine or Dopamine. An adequate blood pressure must be maintained and arrhythmias properly treated. Reversible or contributing causes to the cardiac arrest, such as the H's and T's, need to be identified and treated. Now the second phase of ROSC treatment is to include maintaining and providing neurologic care, along with targeted temperature management. An adequate blood glucose level and adequate sedation, along with appropriate analgesia, should be maintained all during the second phase. In the first hours after resuscitation, the appropriate fluid maintenance need to be administered, depending on the child's hemodynamic condition. It may be important to note that a common cause of morbidity in the later stages after a return of spontaneous circulation results from multi-organ failure or serious brain injury, or even a combination of both. It's important to understand that children who experience ROSC after cardiac arrest may experience a complex combination of pathophysiologic processes, including brain injury, myocardial dysfunction, systemic ischemia, organ system dysfunction, and the persistent conditions that may have led to the cardiac arrest in the first place. In order to stabilize and provide the best outcome for our patient, the treatment of these complicated and multi-system pathologies will most probably require a consultation with pediatric specialists and other expert healthcare provider team members. The key to successful and long-term ROSC is to stabilize the child, provide continuous and close monitoring, and frequent reassessments. The advanced life support provider will want to transfer the patient to appropriate and effective definitive care as soon as feasibly possible.
Every healthcare system should implement a comprehensive and multidisciplinary system of care in a universal and consistent manner for the treatment of post cardiac arrest patients in order to ensure the best outcomes.
In this lesson, we'll cover the goals after the return of spontaneous circulation (also known as ROSC), including the two phases of treatment post resuscitation to help ensure the patient's future survival and long-term care.
When a pediatric patient has a return of spontaneous circulation after cardiac arrest, there are two important phases of care that should follow:
During this phase, you'll continue to provide advanced life support for any immediate life-threatening conditions and focus on the ABC's – airway, breathing, and circulation.
Because respiratory complications and hemodynamic instability are primary early causes of mortality after ROSC, it's vital to provide optimal oxygenation and ventilation.
One of the goals during phase one is keep an SpO2 of greater than 94 percent. Certain diagnostic tools should be utilized to optimize care such as:
In addition, perfusion needs to be stabilized and cardiopulmonary function needs to be monitored.
Another goal during phase one is to treat any persistent shock. This may require fluid boluses of 20ml/kg or medications such as epinephrine and/or dopamine. Adequate blood pressure also must be maintained, and any arrhythmias need to be properly treated.
And lastly, any reversible or contributing causes of the cardiac arrest, such as the H's and the T's, need to be identified and treated.
The main goal during the second phase of care after the return of spontaneous circulation, is to maintain and provide neurologic care for the patient, along with targeted temperature management.
An adequate blood glucose level and adequate sedation, along with the appropriate analgesia, need to be maintained during the second phase of ROSC.
In the first few hours following a successful resuscitation, the appropriate fluid maintenance needs to be administered depending on the child's hemodynamic condition.
Pro Tip #1: It's important to note that the common cause of morbidity in the latter stages following a return of spontaneous circulation typically result from multi-organ failure or serious brain injury, or a combination of both. It's equally important to understand that children who experience a return of spontaneous circulation after cardiac arrest, might also experience a complex combination of pathophysiological processes including:
In order to stabilize the patient and provide the best outcome for them, the treatment of these complicated and multisystem pathologies will most likely require a consultation with a pediatric specialist and other expert healthcare providers and team members.
The key to successful and long-term care following a return of spontaneous circulation includes the following:
And finally, the advanced life support provider will also want to transfer the patient to the appropriate and effective definitive next level of care and do so as soon as possible.