PALS - Pediatric Advanced Life Support Post-Cardiac Arrest Care Questions and Answers — Questions and Answers
Question 1: An 8-year-old child is intubated and mechanically ventilated after achieving Return of Spontaneous Circulation (ROSC). The initial SpO2 reading is 100% while receiving 100% FiO2. What is the most appropriate next step regarding oxygen therapy?
- Maintain FiO2 at 100% for 24 hours to ensure maximal oxygen delivery.
- Immediately perform an arterial blood gas (ABG) before making any changes.
- Titrate FiO2 downwards to achieve a target SpO2 between 94% and 99%. (Correct answer)
- Begin to wean from the ventilator, as 100% saturation indicates stability.
Correct answer: Titrate FiO2 downwards to achieve a target SpO2 between 94% and 99%.
After ROSC, both hypoxia and hyperoxia can be harmful, with hyperoxia potentially causing reperfusion injury from oxygen-free radicals. [1, 4] The PALS guidelines recommend titrating the fraction of inspired oxygen (FiO2) to the lowest level required to maintain an oxygen saturation (SpO2) between 94% and 99%. [1, 2, 4, 5] While an ABG is useful, the immediate action is to reduce the FiO2 to avoid the harmful effects of 100% oxygen.
Question 2: A 5-year-old child remains comatose after ROSC from an out-of-hospital cardiac arrest. Which of the following is a primary goal of targeted temperature management (TTM) for this patient?
- Inducing deep hypothermia below 32°C to minimize all metabolic activity.
- Allowing the patient's temperature to fluctuate naturally.
- Maintaining a slightly elevated temperature (38°C) to promote blood flow.
- Actively preventing or treating fever to maintain normothermia (36°C to 37.5°C). (Correct answer)
Correct answer: Actively preventing or treating fever to maintain normothermia (36°C to 37.5°C).
Post-cardiac arrest fever is common and is associated with worse neurological outcomes. [1, 6] The PALS guidelines strongly recommend targeted temperature management to actively prevent and treat fever, maintaining a core temperature between 36°C and 37.5°C. [1, 7, 18] While a period of induced hypothermia (32°C-34°C) is also an acceptable strategy, the absolute priority is the prevention of hyperthermia. [1, 7, 12]
Question 3: A 7-year-old child achieves ROSC after a witnessed in-hospital cardiac arrest. The team is now implementing the post-cardiac arrest care plan. What is the minimum systolic blood pressure the team should target to avoid hypotension?
- Greater than 100 mmHg
- At least the 5th percentile for age (Correct answer)
- Between 60-70 mmHg
- Equal to the child's diastolic pressure plus 40
Correct answer: At least the 5th percentile for age
Avoiding hypotension is critical for perfusing vital organs after ROSC. The PALS guidelines recommend maintaining a systolic blood pressure of at least the 5th percentile for the child's age. [1] For a child aged 1-10 years, this can be estimated using the formula: 70 + (2 x age in years). For a 7-year-old, this would be 70 + (14) = 84 mmHg.
Question 4: You are managing a comatose toddler in the PICU following a prolonged resuscitation. Continuous EEG monitoring is initiated. What is the primary rationale for this intervention in post-cardiac arrest care?
- To determine the long-term neurologic prognosis within the first hour.
- To detect and guide the treatment of subclinical seizures. (Correct answer)
- To assess the adequacy of cerebral perfusion pressure.
- To ensure the patient is maintained at an adequate level of sedation.
Correct answer: To detect and guide the treatment of subclinical seizures.
Seizures, including non-convulsive or subclinical seizures, are common after cardiac arrest and can worsen secondary brain injury by increasing metabolic demand. [3, 9] Continuous EEG monitoring is recommended for comatose patients to detect these seizures so they can be treated promptly with anticonvulsants. [8, 9]
Question 5: Which of the following assessments are considered essential components of the initial evaluation and management in the immediate post-ROSC period?
- Lumbar puncture and prophylactic antibiotic administration.
- Chest physiotherapy and initiation of enteral feeding.
- Obtaining a 12-lead ECG and monitoring blood glucose levels. (Correct answer)
- Placing a central venous catheter and a pulmonary artery catheter.
Correct answer: Obtaining a 12-lead ECG and monitoring blood glucose levels.
In the immediate post-ROSC phase, it is critical to identify and treat underlying causes and prevent secondary injury. [2, 5] A 12-lead ECG is vital for detecting underlying cardiac pathologies or ischemia. [2] Blood glucose monitoring is also crucial, as both hypoglycemia and hyperglycemia are common and associated with poor neurologic outcomes. [2, 5, 10]
Question 6: A child has been successfully resuscitated and is being managed in the post-cardiac arrest phase. The team is aiming for normocapnia. Which of the following is the most reliable method for continuous monitoring of ventilation status?
- Serial chest X-rays
- Pulse oximetry
- Arterial blood gas analysis every 4 hours
- Waveform capnography (Correct answer)
Correct answer: Waveform capnography
Waveform capnography provides a continuous, real-time measurement of end-tidal CO2 (ETCO2), which reflects the partial pressure of CO2 in arterial blood (PaCO2). [2, 3] This allows for precise titration of mechanical ventilation to achieve normocapnia (avoiding both hypocapnia and hypercapnia), which is crucial for maintaining stable cerebral blood flow. [3, 8] While ABGs are the gold standard for measurement, they are intermittent, whereas capnography is continuous. [1]
PALS - Pediatric Advanced Life Support Post-Cardiac Arrest Care Questions and Answers
An 8-year-old child is intubated and mechanically ventilated after achieving Return of Spontaneous Circulation (ROSC).
The initial SpO2 reading is 100% while receiving 100% FiO2.
What is the most appropriate next step regarding oxygen therapy?