Post-cardiac arrest care in children: Priorities and management

Care priorities	Clinical manifestations	Interventions
Prevent secondary brain injury	Coma Cerebral edema Seizures Myoclonus Sympathetic hyperarousal Long-term neurologic and cognitive deficits	Maintain: Normal oxygenation (pulse oximetry 94 to 99%); avoid hyperoxia (pulse oximetry 100% or P_aO₂ >200 mmHg) Normal p_aCO₂ (35 to 45 mmHg, avoid hypo- or hypercapnia) Blood pressure (see below) Active temperature control (either normothermia or therapeutic hypothermia) Perform continuous EEG monitoring to detect and treat seizures In patients who have normal BP and perfusion, elevate head of bed
Identify and manage cardiovascular dysfunction	Heart failure Myocardial dysfunction that peaks 8 hours after arrest and resolves in 48 to 72 hours Arrhythmias/recurrent arrest	As above and: Maintain systolic blood pressure >5^th percentile for age: Infusion of balanced crystalloid fluids, as needed Continuous infusion vasopressor infusion (fluid-refractory shock), as needed^* Treat arrhythmias/recurrent arrest per PALS
Treat reversible causes	Hs and Ts:	Treatment:
	Respiratory failure (hypoxia)	Oxygenation and ventilation as above
	Hypovolemia	Fluid resuscitation as above
	Hydrogen ion (acidosis)	Ventilation for respiratory acidosis; treat underlying cause of metabolic acidosis, sodium bicarbonate if severe (pH <7.1)
	Hypo- or hyperkalemia	Hypokalemia: Cautious administration of parenteral potassium Hyperkalemia: Parenteral calcium, insulin/glucose, continuous albuterol, and sodium bicarbonate^¶
	Severe hypothermia	Rewarming
	Toxins/drug overdose	Supportive care For selected patients: Antidotes and/or extracorporeal toxin removal^Δ
	Tension pneumothorax	Thoracentesis and thoracostomy tube/pigtail
	Pericardial tamponade	Pericardiocentesis
	Pulmonary embolus	Anticoagulation
	Myocardial infarction (Rare in children)	Thrombolytic therapy and/or percutaneous coronary intervention
Identify and manage systemic ischemia/reperfusion injury		As above and:
	Hyperglycemia	Target glucose 150 to 180 mg/dL^◊
	Coagulopathy	Monitor for and treat DIC^§
	Acute kidney injury	Manage fluid and electrolyte balance, metabolic acidosis, and, rarely, initiate renal replacement therapy
	Capillary leak with intravascular hypovolemia Impaired tissue oxygen utilization	Adjust oxygenation, ventilation, fluid therapy, and vasoactive infusion based upon close monitoring of volume status and tissue oxygenation^¥
	Multi-system organ dysfunction	Provide supportive care; adjust medications, as needed, for kidney and/or hepatic dysfunction

BP: blood pressure; EEG: electroencephalogram; PALS: Pediatric Advanced Life Support.

* Vasopressor options according to blood pressure include:

Hypotensive shock: Continuous infusion of epinephrine or norepinephrine
Normotensive shock: Continuous infusion of epinephrine or, for physicians experienced with its use in children, milrinone

Refer to UpToDate content on Pediatric Advanced Life Support: Management of shock after return of spontaneous circulation.

¶ Refer to UpToDate content on treatment of hyperkalemia in children.

Δ Refer to UpToDate content on occult poisoning in children.

◊ In infants and children, may require continuous infusion of insulin. Refer to UpToDate content on glycemic control in critically ill pediatric patients.

§ Refer to UpToDate content on the management of DIC in children.

¥ Provide sedation and analgesia to control pain and to prevent or manage shivering; use the minimally effective dose to avoid hypotension. Some patients may also require neuromuscular blockade to achieve oxygen saturation or p_aCO₂ targets to prevent shivering, and/or to avoid asynchrony between the patient's breathing and mechanical ventilation. For suggested regiments, refer to UpToDate content on post-cardiac arrest care in children.

Adapted from: Topjian AA, de Caen A, Wainwright MS, et al. Pediatric Post-Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e194.

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Post-cardiac arrest care in children: Priorities and management