PALS Post-Cardiac Arrest Algorithm (Pediatric): Management of Shock After ROSC
Algorithm at a Glance
- Optimize oxygenation and ventilation.
- Treat persistent shock.
- Evaluate Hs and Ts as a contributing factor.
- Treat hypotension.
What are the main steps in PALS post-resuscitation care? The algorithm systematically maps to six major domains (Boxes 1–6):
- Box 1 (Airway/Breathing): Optimize oxygenation and ventilation to maintain target SpO2 and normocapnia.
- Box 2 & 3 (Circulation & Underlying Causes): Assess for persistent shock, push fluids, and aggressively treat Hs and Ts.
- Box 4 & 5 (Pharmacology): Differentiate and treat hypotensive vs. normotensive shock with targeted vasoactive infusions.
- Box 6 (Neuro & Temp): Initiate targeted temperature management, treat seizures, and obtain critical labs.
Note: In the post-ROSC phase, core vital signs (ECG, SpO2, arterial pressure) must be monitored continuously, while neurologic status and perfusion should be reassessed frequently.
What Is the PALS Post-Resuscitation Care Algorithm?
The broader PALS post-resuscitation workflow guides providers through stabilizing a child immediately after cardiac arrest. This specific page focuses exclusively on the shock-management branch of that workflow. This intervention phase matters immensely; post-ROSC children remain at extreme risk for devastating neurologic brain injury, recurrent cardiac arrest, and multi-organ dysfunction if perfusion is not rapidly restored and maintained.
Related Video – Understanding Management of Shock After ROSC Pediatric Algorithm
Goals for Management
Post-resuscitation care is clinically vital because the hours immediately following ROSC heavily dictate the child’s ultimate survival and neurologic outcomes.
The clinician will be able to:
- Identify shock following ROSC after cardiac arrest in the child.
- Understand and treat shock quickly to prevent the child’s deterioration.
- Lead or participate in this algorithm effectively as a PALS-trained clinician or resuscitation team member across ED, ICU, and transport contexts.
The Management of Shock After ROSC Algorithm Explained
Watch our video lesson on Understanding Management of Shock After ROSC Pediatric Algorithm for a complete visual breakdown of this pathway.
This algorithm outlines the steps for assessing and managing children presenting with shock after the return of spontaneous circulation.
Box 1: Optimize Oxygenation and Ventilation
The team titrates oxygen to maintain an oxyhemoglobin saturation of 94–99%. The clinician begins to wean the supplemental oxygen if the saturation is 100%. If necessary, the clinician considers an advanced airway and uses waveform capnography if available. Waveform capnography is the continuous measurement of exhaled carbon dioxide.
Respiratory status is continually monitored to limit exposure to hypercapnia (too much CO2) or hypocapnia (too little CO2). The actionable target here is normocapnia—adjusting ventilation rates to maintain an end-tidal CO2 (PETCO2) between 35 and 45 mm Hg.
Clinicians continually monitor respiratory status after return of spontaneous circulation.
Box 2: Assess For and Treat Persistent Shock
The clinician considers fluid boluses of 10–20 mL/kg of an isotonic crystalloid. (An isotonic crystalloid is a balanced salt solution that matches the body’s normal fluid concentration, such as 0.9% Normal Saline or Lactated Ringer’s).
The team uses caution and lowers the amount of fluid if poor cardiac function is suspected, a scenario reviewed in online PALS recertification courses. Caution: Fluid boluses must be tied to careful, continuous reassessment (listening to lung sounds and checking for hepatomegaly) to ensure the fluid is not causing pulmonary edema.
The provider considers the need for inotropic or vasopressor support for shock that does not respond to fluids.
Normal saline (0.9% sodium chloride) is an example of an isotonic crystalloid.
Box 3: Consider the Hs and Ts as Contributing Factors
During the process, the clinician continuously evaluates the Hs and Ts as possible contributing factors and corrects them if possible.
Shock can be due to metabolic abnormalities, hypovolemia, or cardiac tamponade. The provider considers these as possible contributing factors of shock.
The Hs: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia, Hypothermia, (and Hypoglycemia).
The Ts: Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary).
For a brief review of these potentially reversible causes, watch our Introduction to the Hs and Ts video.
- If the clinician determines the shock is hypotensive, they proceed to Box 4.
- If the clinician determines the shock is normotensive, they proceed to Box 5.
Box 4: Hypotensive Shock
If hypotensive shock is apparent, even after IV bolus fluid therapies, the provider gives IV epinephrine (0.03–0.2 mcg/kg/minute) or norepinephrine (0.03–0.5 mcg/kg/min). Because these are powerful vasoactive infusions, they require continuous arterial blood pressure monitoring and should always follow the latest guidelines and local institutional protocols.
Box 5: Normotensive Shock
This branch applies if the child has persistent shock (poor perfusion, delayed capillary refill, etc.) despite maintaining a normal blood pressure after IV bolus therapy. If this occurs, the clinician treats the child with low-dose epinephrine or milrinone. Milrinone can produce severe hypotension, so it is administered exclusively in a critical care unit by experienced personnel under close continuous monitoring.
Box 6: Other Care
Cardiac arrest takes its toll on multiple organ systems, and after successful resuscitation, the clinician addresses these effects. The treatment includes:
Neurologic Care:
- Treatment of agitation and seizures.
Labs and Diagnostics:
- Treatment of hypoglycemia.
- Obtaining ABGs, electrolytes, and calcium.
Temperature Management:
- Initiation of targeted temperature management (TTM) if the child is comatose.
- Aggressive treatment of fever.
Note: TTM protocols vary. Always follow current guidelines and institutional pathways. Standard options often include maintaining normothermia (36°C-37.5°C) or therapeutic hypothermia (32°C-34°C) for several days.
Disposition:
- Expert consultation and transfer as necessary.
Key Takeaways
Managing shock after ROSC is a highly structured process designed to optimize oxygenation, support circulation, and protect the brain. Providers must remember to immediately target an SpO2 of 94–99%, carefully titrate isotonic fluid boluses (10–20 mL/kg), and quickly escalate to targeted vasoactive infusions (like epinephrine or milrinone) if shock persists. To ensure you have this workflow memorized for your next shift or exam, download and review the printable PALS algorithm PDF.
FAQs
Why is post-resuscitation care important for children?
Because post-ROSC children remain at extreme risk for secondary neurologic injury, recurrent cardiac arrest, and progressive multi-organ dysfunction if their blood pressure and oxygenation are not perfectly stabilized.
How frequently should children be monitored after resuscitation?
They require continuous ECG, SpO2, and vital sign monitoring, alongside frequent physical reassessments of perfusion, ventilation, and neurologic status per protocol.
Who should implement this algorithm?
This algorithm is utilized by PALS-trained clinicians and pediatric resuscitation teams functioning in Emergency Departments, ICUs, and specialized pediatric transport settings.
Related Concepts (Optional Review)
To brush up on foundational concepts mentioned in this post-resuscitation algorithm, review the following brief lessons:
One Quick Question: What is the 421 Formula?
Types of Shock
More Free Resources to Keep You at Your Best
Editorial Note
ACLS Certification Association (ACA) uses only high-quality medical resources and peer-reviewed studies to support the facts within our articles. Explore our editorial process to learn how our content reflects clinical accuracy and the latest best practices in medicine. As an ACA Authorized Training Center, all content is reviewed for medical accuracy by the ACA Medical Review Board.