Initial vitals demonstrate:
T: 34, BP: 50/20, P: 50, O2: 90%.
What is the initial step in management?
Check blood sugar
Cardiac pacing
Administer atropine
Initiate CPR
This patient demonstrates an unstable bradycardia, demonstrated by bradycardia and evidence of poor perfusion. For any pediatric patient with this clinical scenario and a heart rate <60, initiate CPR.
Despite these interventions, clinical scenario is unchanged and child is persistently unresponsive.
What is the next step in management?
Discontinue CPR and intubate
Synchronized cardioversion
Administer epinephrine
The patient remains persistently bradycardia with evidence of poor perfusion despite CPR. The next step in management is administration of epinephrine and consideration of atropine (although epinephrine is the mainstay of treatment). Cardiac pacing would not be first line treatment. Although intubation may ultimately be required, if you are able to support with non-invasive ventilation such as supplemental oxygen or manual bagging, intubation is not emergently required. Even if intubation is deemed necessary, CPR should not be discontinued and any interruptions should be as short as possible (i.e. <10 seconds).
On re-check of pulse, patient is now pulseless and monitor demonstrates the following:
Continue CPR, administer epinephrine every 3-5 minutes
Defibrillate
Continue CPR, administer epinephrine every 10 minutes
The rhythm strip demonstrates asystole. Like PEA arrest, asystole is not amenable to electricity/defibrillation. As such, continue effective CPR, administer epinephrine every 3-5 minutes and continue to attempt to identify underlying cause.
Fortunately, the patient regains a pulse and is demonstrating improving signs of perfusion, although remains unresponsive.
What are the next steps in management?
Continue comprehensive monitoring and assessment, consider pressor support, consider therapeutic hypothermia for persistently comatose patient
Immediately transfer patient to higher level or care
You have completed resuscitation and no further management is required
PALS care is intended to stabilize the patient during the life-threatening event. Our role as providers does not stop here. Post-resuscitation care is meant to optimize ventilation and circulation, preserve organ/tissue function, and maintain recommended blood glucose levels and electrolyte levels. Transfer to higher care may ultimately be necessary but does not preclude the above mentioned monitoring and interventions. Ultimately, therapeutic hypothermia (goal temperature of 32-24 degrees celsius) should be considered in an persistently comatose patient subsequent to cardiac arrest.
