Post-ROSC Management: Immediate Priorities
After achieving return of spontaneous circulation (ROSC), immediately initiate post-cardiac arrest care focusing on optimizing oxygenation, ventilation, hemodynamics, and identifying/treating the underlying cause of arrest. 1
Immediate Airway and Oxygenation Management
Target oxygen saturation of 92-98% to avoid both hypoxia and hyperoxia. 2
- Use 100% inspired oxygen initially until arterial oxygen saturation or partial pressure of arterial oxygen can be measured reliably 2
- Once reliable measurement is available, titrate FiO2 to maintain SpO2 92-98% 3
- Avoid hypoxia (strong recommendation) and avoid hyperoxia (suggested recommendation) 2
Ventilation Targets
Maintain PaCO2 within normal physiological range (35-55 mmHg) as part of post-ROSC bundle of care. 2, 3
- Use ARDSnet protocol for ventilation management 3
- If advanced airway is in place, provide 1 breath every 6 seconds (10 breaths per minute) 1
Hemodynamic Goals
Target mean arterial pressure (MAP) ≥65 mmHg, preferably >80 mmHg, to optimize end-organ and cerebral perfusion. 2, 3
- Hemodynamic goals (MAP, systolic blood pressure) should be considered during post-resuscitation care as part of a bundle of interventions 2
- Use judicious intravenous fluids and vasoactive drugs as needed 4
Diagnostic Evaluation
Obtain 12-lead ECG immediately to identify ST-segment elevation and guide need for emergent coronary angiography. 5
Coronary Angiography Indications:
- ST-segment elevation on ECG post-ROSC = emergent angiography recommended 5, 3
- Consider emergent angiography if:
The 2015 guidelines note that in consecutive post-cardiac arrest patients with suspected cardiovascular cause, coronary artery lesions amenable to emergency treatment were found in 96% with ST elevation and 58% without ST elevation 5. Multiple observational studies demonstrate improved survival and neurologically favorable outcomes with emergency coronary angiography in ST-elevation patients 5.
Temperature Management
For patients who remain unresponsive after ROSC, select and maintain a constant target temperature between 32°C and 36°C for at least 24 hours. 2
Specific Recommendations by Arrest Type:
- Out-of-hospital cardiac arrest with initial shockable rhythm: TTM recommended (strong recommendation) 2
- Out-of-hospital cardiac arrest with initial non-shockable rhythm: TTM suggested 2
- In-hospital cardiac arrest with any initial rhythm who remain unresponsive: TTM suggested 2
Important caveats:
- Do NOT use prehospital cooling with rapid infusion of large volumes of cold IV fluid immediately after ROSC 2
- Prevent and treat fever in persistently comatose adults after completion of TTM 2
- Recent evidence suggests TTM at 32-34°C does not demonstrate improved outcomes compared with targeted normothermia, but fever avoidance remains critical 3
Seizure Management
Glucose Management
Use standard glucose management protocols without modification for post-cardiac arrest patients. 2
- Target blood glucose levels at 6-10 mmol/L 4
Antibiotic Considerations
Reserve antibiotics for patients with evidence of infection. 3
- May be considered if patient is comatose, intubated, and undergoing hypothermic TTM 3
- Do NOT routinely administer corticosteroids 3
Additional Testing
Consider computed tomography head-to-pelvis when the etiology of arrest is unclear 3. Laboratory assessment should evaluate for precipitating causes and assess end-organ injury 3.
Critical Pitfalls to Avoid
- Do not delay coronary angiography in patients with ST-elevation post-ROSC
- Do not use prehospital rapid cooling with large volume cold IV fluids
- Do not allow hyperoxia once reliable oxygen monitoring is available
- Do not use routine seizure prophylaxis (only treat actual seizures)
- Do not prognosticate poor neurologic outcome before 72 hours after ROSC, and extend longer if residual sedation/paralysis confounds examination 2