The PALS Post Arrest Shock Management Algorithm outlines the recommended steps for managing pediatric patients following spontaneous circulation (ROSC) return after cardiac arrest. It emphasizes the critical interventions necessary to stabilize the patient’s condition and optimize their chances of recovery.

The PALS Post Arrest Shock Management Algorithm addresses the critical interventions required following ROSC in pediatric patients. The flowchart below enlists steps that include assessing and maintaining adequate oxygenation and ventilation, optimizing cardiovascular function through fluid resuscitation and inotropic support, monitoring for re-arrest, and understanding the potential causes of the initial arrest to prevent recurrence. By following these steps, healthcare providers can improve the patient’s hemodynamic stability and reduce the risk of re-arrest.

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Explanation of the Flow Chart

  1. Maintain Oxygen Saturation 94%-99%:
    • Ensure the patient’s oxygen saturation levels are between 94% and 99%.
  2. Identify Possible Causes using Hs and Ts:
    • Consider potential underlying causes of the arrest using the Hs and T’s mnemonic:
    • Hypovolemia
    • Hypoxia
    • Hypoglycemia
    • Hypo/Hyperkalemia
    • Hypothermia
    • Tension pneumothorax
    • Toxins
    • Tamponade
    • Trauma
    • Thrombosis
  3. Treat the Cause:

    • Address any identified causes promptly and appropriately.
  4. Bolus with Crystalloids:
    • Administer a bolus of crystalloid solution for fluid resuscitation.
  5. Monitor Carefully:
    •  Continuously monitor the patient’s response and vital signs closely.
  6. If Hypotensive Shock:
    • If the patient is in hypotensive shock, initiate Epinephrine infusion within the specified dosage range.0.1-1 mcg/kg/min
    • Norepinephrine – 0.1-2mcg/kg/min
  7. If Not Hypotensive Shock:
    • Consider other vasopressors based on clinical assessment:
    • Dobutamine: 2-20 mcg/kg/min
    • Norepinephrine: 0.1-2 mcg/kg/min
    • Dopamine: 2-20 mcg/kg/min 
    • Epinephrine: 0.1-0.3 mcg/kg/min
  8. Monitor Blood Glucose, Level of Consciousness, and Serum Electrolytes:
    • Continuously monitor critical parameters and consider transfer to a tertiary center for specialized care if needed.
  9. Consider Hypothermia for Unresponsive Patients:
    • For out-of-hospital cardiac arrest, consider therapeutic hypothermia:
    • Maintain for 5 days at 36 to 37.5°C or 2 days at 32 to 34°C, then 3 days at 36 to 37.5°C if the child remains unresponsive.

Key components of the PALS cardiac arrest algorithm include

The key components of the PALS Post Arrest Shock Management Algorithm focus on stabilizing pediatric patients following the return of spontaneous circulation (ROSC) after cardiac arrest:

  1. Oxygenation and Ventilation: Ensure oxygen saturation levels between 94% and 99% and maintain adequate ventilation.
  2. Identifying Underlying Causes: Use the Hs and T’s to identify potential causes such as hypovolemia, hypoxia, and electrolyte imbalances.
  3. Treating Identified Causes: Address any identified underlying causes promptly and appropriately.
  4. Fluid Resuscitation: Administer isotonic crystalloid boluses for fluid resuscitation to optimize intravascular volume.
  5. Continuous Monitoring: Vigilantly monitor vital signs, including blood pressure, heart rate, and oxygen saturation, to assess the patient’s response.
  6. Vasopressor Therapy: Initiate vasopressor therapy, such as Epinephrine infusion, if the patient is in hypotensive shock.
  7. Consideration of Alternative Vasopressors: Depending on the clinical scenario, consider alternative vasopressors like Dopamine, Norepinephrine, or Dobutamine.
  8. Comprehensive Monitoring and Transfer: Continuously monitor blood glucose levels, level of consciousness, arterial blood gases, and electrolytes. Transfer to a tertiary care centre if needed for specialized care.
  9. Therapeutic Hypothermia Consideration: Evaluate and consider therapeutic hypothermia for unresponsive patients, following specific temperature protocols to mitigate neurological damage.

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