Did you know that there are approximately 20,000 pediatric cardiac arrest cases in the United States annually? Unfortunately, a large percentage of these patients do not survive. As such, it is crucial for healthcare professionals to provide better post-arrest care to cardiac arrest patients. PALS (Pediatric Advanced Life Support) is a training program to assist healthcare providers in managing critically ill pediatric patients effectively.
The program focuses on critical aspects such as cardiac monitoring, shock management, cardiopulmonary resuscitation (CPR), airway management, pharmacology, and post-resuscitation care. The PALS post-arrest shock management algorithm is designed to restore pediatric patients after the return of spontaneous circulation (ROSC) following cardiac arrest. This blog will discuss the latest changes in the algorithm for PALS post-arrest shock management.
PALS post-arrest shock management algorithm
Post-cardiac arrest syndrome is shown in myocardial dysfunction, systemic ischemia, and brain injury. The PALS post-arrest shock management algorithm focuses on the identification and treatment of this complicated physiology to increase the chances of survival. The guidelines for pediatric post-arrest shock management include:
1. Airway and ventilation:
You must ensure the airway is open to monitor the patient’s oxygen level. The patient’s oxygen saturation level should range between 94% and 99%.
2. Identification and treatment of the underlying cause:
Next, you need to assess the underlying causes of the arrest to determine the course of treatment. To do this easily, you can use the Ts and the Hs mnemonics. These will guide you on the factors to examine, including:
- Toxins
- Trauma
- Tamponade
- Thrombosis
- Hypoxia
- Hypovolemia
- Hypoglycemia
- Pneumothorax
- Electrolyte imbalances
3. Fluid resuscitation and vasopressor therapy:
For circulatory support, you need to administer crystalloid fluids and initiate vasopressor therapy if there is a need to manage hypotension.
4. Continuous monitoring and support:
Actively monitor the patient’s response to treatment and observe any vital changes that may occur. Check the vital signs, arterial blood gases, electrolytes, and blood glucose. This will inform you if the patient’s condition is improving and how they are responding to treatment.
5. Vasopressor therapy:
In case the patient is having hypotensive shock, you can initiate vasopressor therapy like an epinephrine infusion.
6. Consider alternative vasopressor:
Based on your clinical context, you can consider alternative vasopressors. These include norepinephrine, dopamine, or dobutamine.
7. Therapeutic hypothermia:
If the patient is unresponsive, you need to consider the patient’s targeted temperature management. This will improve the patient’s neurological outcome.
8. Post-cardiac arrest care:
After you take all the necessary steps of the algorithm, you need to manage the key aspects of the patient’s health. These include renal, neurological, cardiovascular, respiratory, hematologic, and gastrointestinal health.
Updates in PALS post-arrest shock management algorithm
The PALS post-arrest shock management algorithm has certain notable updates. To improve the patient outcome, these guidelines suggest the need to provide:
- Fluid resuscitation:
One of the updates on the PALS post-arrest shock management algorithm is on fluid resuscitation. The protocol emphasizes the need to administer isotonic crystalloid boluses for fluid resuscitation. The rationale behind this update is that isotonic crystalloids such as lactated Ringer’s or normal saline are preferable as they restore the patient’s intravascular volume quickly. This is important to ensure that the patient maintains sufficient perfusion and circulation after the cardiac arrest. To implement this, you need to administer the fluid boluses in increments of 20 mL/kg.
- Vasopressor therapy:
The second update for shock management of pediatric patients after cardiac arrest is on vasopressor therapy. The update requires you to immediately initiate an epinephrine infusion if the patient is having a hypotensive shock. In terms of dosage, the guidelines suggest that you administer the epinephrine infusion from 0.1 to 1 mcg/kg/min. For this, the recommended alternatives are dopamine at a dosage of 2-20 mcg/kg/min or dobutamine with a dosage of 2-20 mcg/kg/min. Both vasopressors should be selected based on a patient’s hemodynamic profile. The rationale behind this guideline is to ensure that the patient’s heart rate and contractility increase using the medication.
- Therapeutic hypothermia:
The PALS guidelines for post-arrest shock management concern therapeutic hypothermia. In case a patient is unresponsive after a cardiac arrest, it is necessary to provide therapeutic hypothermia. The protocol has two options you can choose from:
- Option 1: Ensure that the body temperature ranges between 32°C and 34°C for two days. For the following three days, maintain a temperature of 36°C to 37.5°C.
- Option 2: The second option requires you to regulate the patient’s temperature to a range of 36°C to 37.5°C for five consecutive days.
- Comprehensive monitoring:
The other important update concerns the comprehensive monitoring of the patient’s critical parameters. You need to focus on parameters such as the level of consciousness, blood glucose levels, and serum electrolytes. While at it, vigilantly monitor vital signs of oxygen saturation, heart rate, and blood pressure.
- Post-cardiac arrest care:
The PALS post-arrest shock management algorithm updates on post-cardiac arrest care, specifically on oxygenation. You need to ensure that the oxygen saturation remains at a range of 94% to 99%. You can achieve this by addressing the underlying causes, including toxins, thrombosis, hypothermia, hypoxia, hypovolemia, and trauma. The rationale behind this guideline is to address the reversible causes to improve the patient’s outcome and prevent the recurrence of cardiac arrest.
- Updated vasopressor recommendations:
Another latest update is the vasopressor recommendations on the particular dosages and additional ranges to address refractory cases. You must include a precise dosage adjustment for norepinephrine and epinephrine. To deal with refractory shock cases, consider an agent like milrinone.
Conclusion
Immediately after a pediatric patient’s heart restarts following a cardiac arrest, it is crucial to apply the PALS algorithm. This algorithm provides essential guidelines that assist in stabilizing the patient’s condition and maximizing their chance for recovery. Therefore, as a healthcare provider, you must adhere to the guidelines provided to address key indicators such as monitoring vital signs, managing blood pressure, and ensuring adequate oxygenation and ventilation. By following these guidelines, you can significantly improve the patient’s outcomes and enhance their chances of a full recovery.
