What are the proven ways to increase the likelihood of Return of Spontaneous Circulation (ROSC)?

From the Guidelines

To increase the likelihood of Return of Spontaneous Circulation (ROSC) during cardiac arrest, focus on high-quality CPR with minimal interruptions, early defibrillation for shockable rhythms, and appropriate medication administration, as these interventions have been shown to improve coronary and cerebral perfusion during cardiac arrest, increasing the chances of successful resuscitation and neurologically intact survival 1.

Key Interventions

• Perform chest compressions at a rate of 100-120 compressions per minute with adequate depth (2-2.4 inches) and complete chest recoil, as this has been associated with improved outcomes 1.
• Limit interruptions to less than 10 seconds and prioritize early defibrillation for ventricular fibrillation or pulseless ventricular tachycardia, as timely defibrillation is crucial for successful resuscitation 1.
• Administer epinephrine 1mg IV/IO every 3-5 minutes during resuscitation efforts, as it has been shown to improve short-term outcomes such as ROSC and admission to hospital 1.
• For refractory ventricular fibrillation, consider amiodarone 300mg IV/IO bolus, followed by 150mg if needed, or lidocaine 1-1.5 mg/kg IV/IO initial dose with subsequent doses of 0.5-0.75 mg/kg, as these medications may facilitate successful defibrillation and reduce the risk of recurrent arrhythmias 1.

Additional Considerations

• Address reversible causes using the H's and T's framework (hypoxia, hypovolemia, hydrogen ion/acidosis, hypo/hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis), as identifying and treating underlying causes is essential for successful resuscitation.
• Mechanical CPR devices may help maintain consistent compressions during prolonged resuscitation, and end-tidal CO2 monitoring can guide CPR quality and indicate ROSC when values suddenly increase.

Prioritization

The most critical factor in increasing the likelihood of ROSC is high-quality CPR with minimal interruptions, as this has been consistently shown to improve outcomes in cardiac arrest patients 1.

From the FDA Drug Label

EPINEPHRINE INJECTION, for intravenous use Initial U. S. Approval: 1939 INDICATIONS AND USAGE Epinephrine is a non-selective alpha- and beta-adrenergic agonist indicated to increase mean arterial blood pressure in adult patients with hypotension associated with septic shock.

The proven way to increase the likelihood of Return of Spontaneous Circulation (ROSC) is not directly mentioned in the provided drug label. However, the label does indicate that epinephrine is used to increase mean arterial blood pressure in adult patients with hypotension associated with septic shock, which can be a related condition.

• The key point is that epinephrine is used to increase blood pressure, which may be beneficial in certain cardiac conditions. However, since the label does not directly address ROSC, no conclusion can be drawn about the use of epinephrine to increase the likelihood of ROSC 2.

From the Research

Proven Ways to Increase the Likelihood of Return of Spontaneous Circulation (ROSC)

• Rapid and effective reversal of myocardial ischemia is crucial for return of cardiac activity with spontaneous circulation after failure of external defibrillation 3
• Continuous monitoring of end-tidal carbon dioxide (PETCO2) provides a noninvasive quantitative indication of both systemic blood flow and coronary perfusion pressure, and predicts the likelihood of successful resuscitation 3
• Alpha-adrenergic agents, such as epinephrine, increase coronary perfusion pressure and are of proven benefit in cardiac resuscitation 3
• Minimizing pre- and post-defibrillation pauses increases the likelihood of ROSC, with optimal pre-shock interval of <3s and optimal post-shock interval of <6s 4
• Administration of vasopressors, such as epinephrine and vasopressin, within a certain time frame (e.g. within 10 minutes of arrest) increases the likelihood of ROSC, with the odds of ROSC declining by 4% for every 1-minute delay between call receipt and vasopressor administration 5
• The change in diastolic blood pressure (DBP) following epinephrine administration during pediatric in-hospital CPR is associated with return of spontaneous circulation, with a DBP response of ≥5 mmHg characterized as "responders" 6

Factors Influencing ROSC

• Time to first CPR, time to first drug administration, and time to first shock are predictors of ROSC 7
• The use of a drug cocktail, including propanolol, epinephrine, and vasopressin, increases the likelihood of ROSC 7
• High-dose epinephrine (0.1 mg/kg) increases the likelihood of ROSC 7
• Patient factors, such as age, race, and gender, may influence the likelihood of ROSC, with males and patients receiving bystander CPR less likely to attain ROSC 5