What immediate steps should be taken in a post-cardiac arrest patient regarding glucose level, extubation, epinephrine administration, and targeted temperature management?

Immediate Post-Cardiac Arrest Management After ROSC

Check the glucose level and initiate targeted temperature management immediately—do not extubate, and do not administer epinephrine post-ROSC.

Priority Actions in the Immediate Post-ROSC Period

1. Glucose Monitoring (Check Immediately)

Measure blood glucose immediately and maintain levels below 180 mg/dL (10 mmol/L) while strictly avoiding hypoglycemia 1. This is a critical early intervention that directly impacts neurological outcomes.

• Blood glucose should be checked as part of the initial post-ROSC assessment 1
• Target moderate glycemic control at 144-180 mg/dL (8-10 mmol/L) 1
• Do not implement strict glucose control (80-110 mg/dL) as this significantly increases the risk of dangerous hypoglycemia 1
• High blood glucose after resuscitation is strongly associated with poor neurological outcomes 1
• Hypoglycemia is particularly dangerous in comatose patients who cannot report symptoms 1

2. Targeted Temperature Management (Initiate Immediately)

Begin TTM immediately for all comatose patients after ROSC, selecting and maintaining a constant target temperature between 32°C and 36°C for at least 24 hours 1.

• TTM is strongly recommended for out-of-hospital cardiac arrest with initial shockable rhythm (like ventricular fibrillation) who remain unresponsive after ROSC 1
• TTM is also suggested for non-shockable rhythms and in-hospital cardiac arrest patients who remain comatose 1
• The neuroprotective effects work by suppressing pathways leading to delayed cell death and reducing cerebral metabolic oxygen demand 1
• Duration should be at least 24 hours 1
• Do not use rapid infusion of large volumes of cold IV fluid for prehospital cooling 1
• Actively prevent and treat fever after the TTM period, as hyperthermia is associated with worse outcomes 1

3. Extubation (Do NOT Perform)

Do not extubate immediately post-ROSC—the patient requires continued mechanical ventilation for airway protection, oxygenation optimization, and ventilation control 1.

• Comatose post-cardiac arrest patients cannot protect their airway
• Precise control of oxygenation and ventilation is essential in the immediate post-ROSC period 1
• Use the highest available oxygen concentration initially until arterial blood gases can be measured 1
• Once monitoring is available, titrate FiO₂ to maintain oxygen saturation 94-100% while avoiding hyperoxia 1
• Maintain PaCO₂ within normal physiological range 1

4. Epinephrine Administration (Do NOT Give)

Do not administer epinephrine after ROSC is achieved—epinephrine is only indicated during active cardiac arrest, not in the post-resuscitation phase 2.

• Epinephrine is a resuscitation drug used during cardiac arrest to restore circulation
• Once ROSC is achieved, the indication for epinephrine has ended
• Post-ROSC hemodynamic support should use goal-directed therapy with fluids and appropriate vasopressors/inotropes (such as norepinephrine, dobutamine, or milrinone) titrated to specific hemodynamic targets 1
• Target mean arterial pressure ≥65 mmHg using appropriate vasopressors if needed 1

Critical Pitfalls to Avoid

• Never implement tight glucose control (80-110 mg/dL) as this increases mortality risk through hypoglycemia 1
• Do not delay TTM initiation—neuroprotection is time-sensitive 1
• Avoid both hypoxia and hyperoxia—titrate oxygen carefully once monitoring is available 1
• Do not confuse resuscitation drugs with post-ROSC management—epinephrine has no role after ROSC 2
• Monitor for and treat seizures if they occur, but do not use prophylactic anticonvulsants 1

Additional Post-ROSC Bundle Elements

Beyond the four options presented, comprehensive post-cardiac arrest care includes:

• Hemodynamic monitoring and optimization with fluids/vasopressors to maintain adequate perfusion 1
• Consideration of emergent coronary angiography if indicated 1
• Continuous or frequent EEG monitoring to detect seizures 1
• Avoidance of hyperthermia throughout the post-arrest period 1