PICU supportive care, monitoring, routine investigations and referral following cardiac arrest

Airway 

Ensure well-positioned ETT on CXR

Breathing

Titrate ventilation to target saturations 94-98%, or as appropriate for the individual patient’s normal saturations (e.g. in chronic lung disease or cyanotic heart disease)

Individualise tidal volumes and PEEP

Titrate ventilation for target pCO2 4.5-5.5

Do not routinely hyperventilate

Circulation

Aim to restore normovolaemia with cautious fluid resuscitation, in patients who are fluid-responsive, using crystalloid 

Consider early use of vasoactive drugs, with drug choice individualised to patient and to suspected aetiology

Target a systolic BP >10^th centile for age

Neurology

Sedation and analgesia as per unit protocol

Do not routinely use NMB, but this can be added if required to achieve effective ventilation and/ or to prevent shivering

Position patient 30 degrees head up and with head in midline

Routine, prophylactic anti-epileptics are not recommended 

Seizures should be managed aggressively, initially using medications as per APLS (or the patient’s individualised seizure plan if appropriate)

Monitor with cerebral NIRS. Consider continuous EEG where available

Fluids and electrolytes

IV fluids at 70% restriction, titrated as required

Aim to keep sodium >140, using boluses of hypertonic saline if required

Gastro and nutrition

Site NG or OG tube, and commence gastroprotection as appropriate

Aim for glucose 4-12mmol/L

Infection

Consider broad spectrum empirical antibiotics if infection is thought to be a likely aetiological factor in the cardiac arrest 

Lines

Consider establishing central venous access, ideally using femoral vein

Establish arterial access for invasive blood pressure monitoring 

Temperature

Monitor central temperature 

Target temperature 36.0 – 37.0C. Avoid pyrexia (i.e. keep <37.5C) for 72 hours. Use active cooling measures if required 

Airway/ breathing

Chest X-ray should be performed

Circulation

12 lead ECG should be performed

Echocardiogram should be considered in all cases, and discussed with Cardiology

The appropriateness of other investigations (e.g. 24hr ECG, cardiac genetics etc.) should be discussed with Cardiology

Neurological 

CT brain should be undertaken as soon as possible if there is suspicion of a reversible, intracranial cause for cardiac arrest. Early CT brain should not be undertaken solely for prognostication 

Request should be made for MRI brain to be undertaken after at least 72 hours of neuroprotective intensive care. This should ideally be undertaken between 3-5 days following cardiac arrest 

Discuss with Neurology on day one of PICU admission post-arrest, to obtain EEG and request their review and assistance with prognostication

Child protection

Consider early discussion with Child Protection service if there are any concerns around Non Accidental Injury. Requests for further investigation of NAI (other than CT brain which should be undertaken if there is clinical suspicion of intracranial abnormality) should be discussed with Child Protection 

Metabolic 

Obtain and send ammonia in all cases of cardiac arrest

Discuss with Metabolic service if there is a suspicion of underlying Metabolic cause

Toxicology

Consider sending urine toxicology if intoxication is suspected

Microbiology

Obtain blood cultures, including of central lines if in situ

Obtain samples for respiratory virology

Pregnancy 

Send hCG for pubertal girls/ young women  

Psychology

Make a referral to Psychology for parents/ carers/ other family as appropriate

GP

Inform the patient’s General Practitioner of cardiac arrest and PICU admission, by telephone