Cardiorespiratory arrest and post-arrest care — branching viva

Branch 1 — Confirming and managing the arrest

Examiner. How do you confirm this child is in arrest, and what are the first three things you do?[2]

Confirm in under 10 seconds: unresponsive, no normal breathing (gasping is agonal and counts as a respiratory arrest sign), and no central pulse (carotid or femoral, brachial in a young infant). The first three actions are call for help, start high-quality chest compressions, and ventilate with 100 percent oxygen by bag-valve-mask, using 15 compressions to 2 ventilations with two rescuers.[2][3]

Branch 2 — Drugs, rhythm and defibrillation

Examiner. The monitor shows ventricular fibrillation. Walk me through the next two minutes and give your drug doses.[2]

Defibrillate immediately at 2 to 4 J per kg (28 to 56 J for 14 kg), resume compressions without pausing to check the rhythm, and establish intraosseous access. Continue the two-minute CPR cycle, then check the rhythm. After the second shock give adrenaline 10 micrograms per kg (0.1 mL per kg of 1 in 10,000 — 1.4 mL for 14 kg) every 3 to 5 minutes, and after the third shock give amiodarone 5 mg per kg (70 mg), escalating the shock energy to at least 4 J per kg up to 10 J per kg. Voice the 4 Hs and 4 Ts every cycle and correct hypoxia first.[2][3]

Branch 3 — ROSC and high-quality CPR

Examiner. Return of spontaneous circulation is achieved. How did you know, and what made the CPR effective?[8]

A palpable pulse returns, the end-tidal CO2 rises abruptly, and an organised rhythm appears with a measurable blood pressure. Effective CPR means depth about one third of the chest, rate 100 to 120 per minute, full recoil, minimised interruptions (under 10 seconds for rhythm checks), and no excessive ventilation. Physiologic, feedback-guided CPR titrated to arterial pressure and end-tidal CO2 improved survival with favourable neurologic outcome in the ICU-RESUS trial.[8]

Branch 4 — The post-arrest bundle

Examiner. She is now intubated and comatose in PICU with a temperature of 37.9 degrees C and an MAP at the 10th percentile. What is your bundle?[1]

Targeted temperature management to 36 to 37.5 degrees C with active normothermia — treat her 37.9 degrees C now, because THAPCA showed hypothermia is not superior to normothermia and fever worsens injury. Normoxia SpO2 94 to 99 percent (wean FiO2, avoid hyperoxia), normocarbia PaCO2 35 to 45 mmHg, restore an age-appropriate MAP with a vasoactive infusion because hypotension is linked to poor outcome, control glucose, and apply continuous EEG to detect and treat seizures.[1][3]

Branch 5 — Prognostication and family

Examiner. When and how do you prognosticate, and what do you tell the family?[1]

Prognostication is delayed and multimodal: wait at least 72 hours after ROSC, then combine examination, continuous EEG, somatosensory evoked potentials, neuroimaging and biomarkers, never on a single early sign. Tell the family honestly that the outcome is uncertain in the first days, that you are protecting her brain and treating the cause, and that decisions about the level of treatment will rest on concordant, serial evidence once she is past the acute phase.[1]