6.6 Post-Resuscitation Care, Defibrillation & Cardioversion in Transit, ECMO Indications & the Transport-vs-Stay Decision
Key Takeaways
After return of circulation in children, the 2025 AHA/AAP guidelines recommend keeping systolic and mean arterial pressure above the 10th percentile for age; oxygen is titrated to an SpO2 of about 94–99% while avoiding both hypoxemia and hyperoxemia.
Post-arrest care targets the NCC-listed problems of acidosis (fix ventilation and perfusion rather than giving routine bicarbonate), third spacing (capillary leak), and glucose (avoid hypoglycemia and marked hyperglycemia).
For infants, a manual defibrillator is preferred; if one is not available, an AED with a pediatric dose attenuator is used. Synchronized mode must be confirmed before every cardioversion shock.
Commonly used neonatal ECMO criteria include an oxygenation index above 40, gestational age of about 34 weeks or more, weight of about 2 kg or more, and potentially reversible disease; refer early rather than at the point of collapse.
The transport-versus-stay decision weighs time-critical definitive care against procedures that are safer before departure; a patient with an unsecured airway or an undrained pneumothorax is rarely safer in a moving vehicle.
Post-Resuscitation Care, Electrical Therapy, ECMO & the Transport-vs-Stay Decision
Section 6.4 covers NRP and PALS algorithms. This section covers what happens around them: the fragile period after return of spontaneous circulation (ROSC), electrical therapy in a moving vehicle, extracorporeal life support, and the judgment call that the NCC outline calls "knowing when to transport vs stay."
Post-Arrest Care
After ROSC, the heart is stunned, the capillaries leak, and the brain is at risk of secondary injury. Transport teams often care for these patients in the first hours.
Hemodynamic and respiratory targets
- Blood pressure: The 2025 AHA/AAP pediatric guidelines recommend keeping systolic and mean arterial pressure above the 10th percentile for age after cardiac arrest. Hypotension occurs in 25–50% of children after ROSC.
- Oxygen: Titrate to normal saturations (commonly SpO2 94–99%). Avoid both hypoxemia and hyperoxemia (PALS; NCC's own sample question uses "less than 100% but at least 94%").
- Ventilation: Aim for normocapnia appropriate to the patient. Hyperventilation lowers cerebral blood flow.
- Temperature: Prevent fever. Follow targeted temperature management protocols for comatose children after cardiac arrest, and therapeutic hypothermia criteria for neonatal HIE (Section 9.1).
- Seizures: Post-arrest seizures are often subclinical. Continuous EEG is recommended in hospital. In transport, watch for autonomic signs.
The three NCC post-arrest problems
| Problem | Why it happens | Transport management |
|---|---|---|
| Acidosis | Lactate from global ischemia plus CO2 retention | Restore ventilation and perfusion first. Sodium bicarbonate is not routine in arrest; reserve it for specific indications (hyperkalemia, tricyclic or sodium-channel-blocker toxicity), and NRP does not recommend it during neonatal resuscitation. |
| Third spacing | Ischemia-reperfusion injures the endothelium, so plasma leaks into tissues | Expect edema with intravascular depletion. Give fluid in measured boluses with frequent reassessment, add vasoactive support early, and track totals. Pulmonary edema may worsen oxygenation. |
| Glucose | Stress hyperglycemia, or hypoglycemia from depleted glycogen (especially neonates) | Check glucose early and repeatedly. Treat hypoglycemia promptly (D10W 2 mL/kg in neonates; Sections 9.3 and 13.1) and avoid large dextrose loads that cause marked hyperglycemia. |
Defibrillation and Cardioversion in Transport
| Topic | Key points |
|---|---|
| Doses | Defibrillation 2 J/kg, then 4 J/kg, then ≥4 J/kg up to 10 J/kg or the adult dose. Synchronized cardioversion 0.5–1 J/kg, then 2 J/kg (Section 6.4). |
| Device choice | For infants, a manual defibrillator is preferred. If none is available, use an AED with a pediatric dose attenuator. If neither is available, use a standard AED. |
| Pads | Use the largest pads that fit without touching (infant pads for small infants). Use anterior-posterior placement when anterior-lateral pads would overlap. |
| Synchronization | Confirm the sync markers on each R wave before every cardioversion. Many monitors revert to unsynchronized mode after a shock. |
| Vehicle and aircraft safety | Announce the shock, make sure no one touches the patient or stretcher, keep free-flowing oxygen away from the chest, and follow program rules for informing the pilot. Transport defibrillators are installed and used under aviation equipment approvals. |
| Motion artifact | Vibration mimics VF or VT (Section 3.3). Confirm pulselessness clinically before shocking. Ground crews may briefly stop the vehicle for AED analysis. |
The 2025 pediatric guidelines also recommend giving epinephrine as early as possible for arrests with an initial non-shockable rhythm. With an arterial line in place, it may be reasonable to target a diastolic pressure of at least 25 mmHg in infants and 30 mmHg in children during CPR.
ECMO: Indications, Referral, and Mobile ECMO
Extracorporeal membrane oxygenation (ECMO) supports gas exchange (venovenous) or gas exchange plus circulation (venoarterial) while the lungs or heart recover.
Neonatal respiratory ECMO (commonly used ELSO-based criteria)
- Gestational age about 34 weeks or more and weight about 2 kg or more (bleeding and IVH risk rise below these)
- Oxygenation index above 40 for several hours, or failure to wean from 100% oxygen despite maximal therapy
- Severe hypoxic respiratory failure with acute decompensation, or pulmonary hypertension with ventricular dysfunction or pressor-resistant hypotension
- Potentially reversible disease (MAS, PPHN, sepsis/pneumonia, CDH) and usually no more than 10–14 days of high-pressure ventilation
- Common exclusions: lethal chromosomal anomalies, major intracranial hemorrhage, irreversible brain injury, and uncontrolled bleeding
Pediatric ECMO
- Refractory respiratory failure (severe PARDS unresponsive to lung-protective strategies; Section 11.3)
- Refractory cardiogenic shock (myocarditis, cardiomyopathy, post-cardiac surgery; Sections 12.2–12.3)
- Extracorporeal CPR (ECPR): The AHA considers ECPR for selected in-hospital arrests (especially in children with cardiac disease) in centers with established programs.
Referral timing
The most important transport lesson is to refer early. A patient whose OI is climbing from 25 to 35 despite iNO is safer to move than one at OI 60 on maximal settings. When a patient becomes too unstable to move conventionally, a mobile ECMO team can cannulate at the referring hospital and transport the patient on ECMO.
Knowing When to Transport Versus Stay
There is no single rule, but the decision can be structured:
| Question | Favors leaving promptly | Favors staying to stabilize (or not moving) |
|---|---|---|
| Does the patient need care only the receiving center provides? | Expanding epidural hematoma, midgut volvulus, uncontrolled hemorrhage needing surgery, ductal lesion needing a cardiac center | Problems the team can fix at the bedside (airway, access, glucose, pneumothorax) |
| Can a critical procedure be done more safely before departure? | Already done | Unsecured airway, undrained pneumothorax before flight, no reliable access, gastric distension |
| Is the patient too unstable to survive the journey? | Stable enough on current support | Ongoing CPR without an ECPR destination, refractory hypoxemia at maximal support (consider mobile ECMO or bringing specialists to the patient) |
| Will the environment make things worse? | Ground transport available, weather acceptable | Aircraft altitude would expand trapped gas, weather below minimums, prolonged transport time |
| What do the family and goals of care say? | Family wants tertiary care | Imminent, unavoidable death where comfort care at the referring hospital is kinder (Section 1.3) |
Practical rules:
- "Scoop and run" is appropriate only when definitive care is time-critical and cannot be provided locally, and even then the airway, breathing, and vascular access should be secured first.
- Procedures are harder and more dangerous in a moving vehicle. Intubation, chest tubes, and central access should be done before departure whenever the need is foreseeable.
- If a patient arrests in transit, consider diversion to the nearest capable facility and discuss it with medical control.
- Mission cancellation or delay is a legitimate outcome when the patient improves, dies, or cannot be safely moved. Document the reasoning and the medical control discussion.
Transport Scenario
A 39-week neonate with meconium aspiration is on HFOV at the referring NICU with iNO 20 ppm and an OI rising from 28 to 38 over three hours. The receiving center offers ECMO. The team decides to move now: the infant meets ECMO referral criteria, and waiting could make any transport impossible. The chest is decompressed with a pre-existing chest tube to a Heimlich valve, the transport uses ground ambulance because of weather, and iNO continues without interruption. On arrival the OI is 44, and the infant is cannulated for venoarterial ECMO within an hour.
A 4-year-old has ROSC after a 12-minute in-hospital arrest. Which post-resuscitation target is most consistent with current AHA/AAP pediatric guidance?
Hyperventilate to a PaCO2 of 25–30 mmHg to reduce cerebral edema
Give sodium bicarbonate every 10 minutes until the pH is normal
Maintain SpO2 at 100% on FiO2 1.0 for 24 hours
Keep systolic and mean arterial pressure above the 10th percentile for age and titrate oxygen to an SpO2 of about 94–99%
A transport team prepares to cardiovert a 7-month-old in unstable SVT. The first synchronized shock at 0.5 J/kg fails. Before delivering a second shock at 1 J/kg, what must the clinician confirm?
That the device is in unsynchronized mode for a higher-energy shock
That the pads have been moved to the lower abdomen
That synchronization markers are present on each R wave, because many devices revert to unsynchronized mode after a shock
That the infant has received a second dose of atropine
A 38-week neonate with PPHN has an oxygenation index rising from 26 to 36 over four hours despite iNO and optimal ventilation. The nearest ECMO center is 90 minutes away by ground. What is the most appropriate transport decision?
Wait until the oxygenation index exceeds 60 to confirm ECMO is truly needed
Transport now to the ECMO center while the infant can still tolerate conventional transport, continuing iNO without interruption
Stop iNO before transport to avoid equipment problems
Delay transport until a chest radiograph can be repeated in 12 hours
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