Post-Cardiac Arrest Care and Team Dynamics
After return of spontaneous circulation, the goal shifts from restarting the heart to protecting the brain and preventing rearrest.
Titrate oxygen to an SpO2 of roughly 94%–99% and wean unnecessary 100% oxygen, since hyperoxia contributes to reperfusion injury. Ventilate to normocarbia, about an ETCO2 of 35–45 mmHg: hyperventilation causes cerebral vasoconstriction and hypocarbic ischemia, while hypoventilation raises intracranial pressure.
Support blood pressure, because post-arrest hypotension worsens outcome. Give isotonic fluid boluses and start a vasoactive infusion to keep systolic pressure above the fifth percentile for age. Check and treat glucose, calcium, and electrolytes, obtain a 12-lead ECG, chest radiograph, and blood gas, and treat seizures aggressively. Comatose children after arrest are candidates for targeted temperature management, either therapeutic hypothermia or strict normothermia per protocol, and fever must be avoided. Prognostication should wait at least 72 hours and use multiple modalities.
Team performance is scored. Assign explicit roles, use closed-loop communication ("I am giving 0.1 mg epinephrine IV now" - "received"), switch compressors every 2 minutes, and use the rhythm check to summarize and re-plan. Speak up early using a shared-concern model: state the concern, the problem, and the action you want. Debrief afterward.
Traps: hyperventilating the post-arrest child, chasing a saturation of 100%, pausing compressions to talk, and leaving the team without a named leader.
Worked example: after ROSC, set FiO2 to keep SpO2 at 94%–99% and adjust the ventilation rate to keep ETCO2 at 35–45 mmHg.