ROSC Intubation Protocol
After Return of Spontaneous Circulation (ROSC), advanced airway management should include endotracheal intubation or supraglottic airway placement with continuous waveform capnography monitoring, followed by ventilation at 10 breaths per minute with continuous chest compressions if needed. 1
Immediate Post-ROSC Airway Management
- Once an advanced airway is placed after ROSC, provide 1 breath every 6 seconds (10 breaths per minute) with continuous chest compressions if needed 1
- Use waveform capnography or capnometry to confirm and monitor endotracheal tube placement 1
- Avoid excessive ventilation as it can increase intrathoracic pressure and decrease cardiac output 1
Advanced Airway Options
- Endotracheal intubation remains a standard option but requires skilled providers 1
- Supraglottic airway devices are acceptable alternatives if endotracheal intubation is challenging or provider experience is limited 1
- Video laryngoscopy should be considered as it's associated with better neurological outcomes in OHCA patients with ROSC (OR = 1.34,95% CI = 1.12-1.61) 2
First-Pass Success Importance
- First-pass intubation success is associated with higher rates of ROSC (OR = 5.281,95% CI: 1.800-15.494) 3
- Use of capnography significantly improves first-pass success (OR = 7.384,95% CI 1.886-28.917) 3
- Failed initial intubation attempts can decrease ACLS effectiveness and potentially delay time to ROSC 3
Post-Intubation Management
- Target oxygen saturation of 92-98% using ARDSnet protocol 4
- Maintain PaCO2 within normal physiologic range (35-55 mmHg) 4
- Avoid hyperventilation as it can cause cerebral vasoconstriction and decreased cerebral perfusion 1
- Target mean arterial pressure of at least 65 mmHg, preferably >80 mmHg, to improve end-organ and cerebral perfusion 4
Monitoring After ROSC
- Continuously monitor end-tidal CO2 (ETCO2) - abrupt sustained increase (typically >40 mmHg) indicates ROSC 1
- Monitor pulse and blood pressure 1
- Consider near-infrared spectroscopy (NIRS) for non-invasive detection of cerebral oxygenation and ROSC without interrupting compressions 5
Special Considerations
- In pregnant patients with ROSC, anticipate difficult airway management and use the most experienced provider available 1
- For pediatric patients with ROSC after OHCA, prevent fever and consider moderate therapeutic hypothermia or strict maintenance of normothermia 1
- For suspected opioid overdose with ROSC, continue respiratory support and consider additional naloxone administration per protocol 1
Common Pitfalls to Avoid
- Interrupting chest compressions for prolonged periods during intubation attempts 1
- Failing to confirm tube placement with waveform capnography 1
- Hyperventilation which can decrease cerebral perfusion 1
- Using ETCO2 threshold values alone to predict mortality or decide to terminate resuscitation 1
- Delaying other critical post-ROSC interventions (e.g., treating reversible causes, considering coronary intervention for STEMI) 1
Remember that post-ROSC patients are critically ill with a complex post-cardiac arrest syndrome that may include hypoxic brain injury, myocardial dysfunction, systemic ischemia/reperfusion injury, and persistent precipitating pathophysiology 4. Proper airway management is just one component of comprehensive post-ROSC care.