Manage a child after cardiac arrest in PICU — OSCE

Candidate brief

This child has achieved ROSC but is now in post-cardiac arrest syndrome with four active harms that will worsen her secondary brain injury if not corrected: fever, hyperoxia, hypocarbia and relative hypotension. Your task in this station is to recognise each harm and deliver the post-arrest bundle.[1][3]

Structured approach

Temperature. Treat the 38.0 degrees C fever immediately with paracetamol and surface or intravascular cooling, and target a steady 36 to 37.5 degrees C. Therapeutic hypothermia is not superior to normothermia after the THAPCA trials, but hyperthermia is harmful, so fever avoidance is mandatory.[1]

Oxygenation. Her SpO2 of 100 percent on FiO2 1.0 is hyperoxia — wean the FiO2 stepwise to the lowest value keeping SpO2 at 94 to 99 percent, because observational data link hyperoxia to worse survival and neurologic outcome.[1][10]

Ventilation. Her PaCO2 of 28 mmHg is hypocarbia from over-ventilation — reduce the minute volume to target normocarbia PaCO2 35 to 45 mmHg (4.7 to 6.0 kPa), because hypocarbia causes cerebral vasoconstriction and worsens ischaemia. Use lung-protective settings.[1]

Circulation. Her MAP of 56 mmHg is low for her age and hypotension is associated with poor outcome — start a vasoactive infusion, guided by the post-arrest blood-pressure thresholds from the ICU-Resuscitation study, and assess myocardial function with echocardiography; add milrinone for low cardiac output with high filling pressures. Give a cautious 5 to 10 mL per kg bolus only if hypovolaemic, avoiding overload.[1][9]

Brain. Continue the continuous EEG and treat any clinical or electrographic seizure; monitor glucose and avoid hypoglycaemia and marked hyperglycaemia; keep the head midline and elevated 30 degrees. Treat the precipitant — severe asthma — in parallel.[1]

Communication

Tell the family that she has been resuscitated and is now in a critical-care phase aimed at protecting her brain, that her body temperature, oxygen, ventilation and blood pressure are being actively optimised, and that it is too early to predict her neurologic outcome — that assessment will be made at least 72 hours after ROSC using a combination of examination, EEG, evoked potentials and imaging.[1]

Examiner's checklist

Did the candidate recognise all four harms (fever, hyperoxia, hypocarbia, hypotension)? Did they state the normothermia target of 36 to 37.5 degrees C, the normoxia target of SpO2 94 to 99 percent, the normocarbia target of PaCO2 35 to 45 mmHg, and the need to restore an age-appropriate blood pressure with a vasoactive infusion? Did they keep the continuous EEG and plan delayed multimodal prognostication? Did they communicate honestly with the family?[1][3]