Cardiac arrest and post-ROSC care

Run high-quality CPR and ALS for shockable and non-shockable rhythms, find and fix the Hs and Ts, manage peri-arrest rhythms, then deliver a structured post-ROSC bundle, fever prevention and safe multimodal neuroprognostication.

7 topics

01
Recognition and high-quality CPR
Recognise arrest in under 10 s, start compressions immediately at 100-120/min and 5-6 cm depth, attach the defibrillator, and protect compression fraction.
8 stepsAlgorithmNew
02
ALS: shockable rhythms (VF / pulseless VT)
Shock early, resume CPR immediately for 2 min, give adrenaline after initial shocks fail and amiodarone (or lidocaine) for persisting VF, and treat the cause.
7 stepsAlgorithm3 dosesNew
03
ALS: PEA, asystole and the reversible causes (Hs and Ts)
Give adrenaline as soon as possible, keep CPR going, and actively search for and treat the 4 Hs and 4 Ts, using POCUS only without interrupting compressions.
7 stepsAlgorithm4 dosesNew
04
Peri-arrest rhythms: unstable tachycardia and bradycardia
Decide if the patient is unstable (shock, syncope, ischaemia, heart failure). Unstable tachycardia: synchronised cardioversion. Unstable bradycardia: atropine, then adrenaline infusion or pacing.
7 stepsAlgorithm5 dosesNew
05
Post-ROSC care: the first hours
Secure the airway, titrate oxygen to SpO2 92-98%, keep normocapnia and MAP ≥ 65 mmHg, get a 12-lead ECG, decide on angiography, find the cause, and plan temperature control and neuroprotection.
9 stepsAlgorithm2 dosesNew
06
Temperature control after cardiac arrest
In patients who remain comatose after ROSC, actively prevent fever (≤ 37.5 °C) for at least 72 h. Hypothermia at 32-36 °C is acceptable but not proven better.
7 stepsAlgorithmNew
07
Neuroprognostication after cardiac arrest
Never decide on prognosis early. At ≥ 72 h after ROSC (and after sedation clears), combine examination, EEG, SSEP, NSE and imaging; poor outcome is likely only when two or more predictors agree.
6 stepsAlgorithmNew

Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Adrenaline (epinephrine)

Catecholamine vasopressor

Indications: All cardiac arrest rhythms; post-ROSC shock or symptomatic bradycardia as an infusion; anaphylaxis (IM).
Adult dose: Arrest: 1 mg IV/IO every 3-5 min (every second 2-min CPR cycle). Non-shockable: as soon as access is obtained. Shockable: after initial defibrillation attempts fail (ERC: after the 3rd shock; AHA: after initial shocks). Bradycardia or shock infusion: 2-10 mcg/min (≈ 0.02-0.15 mcg/kg/min).
Preparation (India): 1 mg/mL (1:1000) ampoules are standard in India. For arrest: give 1 mL undiluted and flush with 20 mL NS, or dilute 1 mg to 10 mL (100 mcg/mL). Infusion: 4 mg in 50 mL (80 mcg/mL).
Cautions: High-dose adrenaline is not recommended. Tachyarrhythmias and hypertension after ROSC: stop the bolus schedule once ROSC is achieved.

Amiodarone

Class III antiarrhythmic

Indications: VF/pulseless VT persisting after shocks; stable VT; AF rate/rhythm control in the critically ill.
Adult dose: Arrest: 300 mg IV/IO bolus after the 3rd shock, then 150 mg after the 5th shock (ERC); AHA: 300 mg then 150 mg. Stable VT or after ROSC: 150 mg over 10 min, then 1 mg/min for 6 h, then 0.5 mg/min for 18 h (max ~2.2 g/24 h).
Preparation (India): 150 mg/3 mL ampoules. In arrest, 300 mg (2 ampoules) can be pushed and flushed. Infusions must be made in 5% dextrose (e.g. 900 mg in 500 mL D5 or 300 mg in 50 mL D5 via central line).
Cautions: Hypotension and bradycardia (polysorbate solvent); phlebitis peripherally; QT prolongation; long-term thyroid, liver and lung toxicity.

Lidocaine (lignocaine)

Class IB antiarrhythmic

Indications: Alternative to amiodarone for shock-refractory VF/pVT.
Adult dose: 1-1.5 mg/kg IV/IO, then 0.5-0.75 mg/kg every 5-10 min if needed (max 3 mg/kg). Maintenance after ROSC 1-4 mg/min.
Preparation (India): 2% (20 mg/mL) preservative-free plain lignocaine for IV use (do NOT use the adrenaline-containing local anaesthetic vials).
Cautions: CNS toxicity (seizures) and myocardial depression at high levels, especially in liver failure.

Atropine

Antimuscarinic

Indications: Symptomatic or unstable bradycardia; organophosphate poisoning (very different doses, see module 28). Not used routinely in PEA/asystole.
Adult dose: Bradycardia: AHA 1 mg IV every 3-5 min (max 3 mg); ERC 500 mcg IV, repeat every 3-5 min to max 3 mg.
Preparation (India): Commonly 0.6 mg/mL ampoules in India: 1 mg ≈ 1.7 mL, 0.5 mg ≈ 0.8 mL. Push fast and flush.
Cautions: Often ineffective in heart transplant patients and in infranodal (Mobitz II / complete) block with wide QRS. Doses < 0.5 mg can cause paradoxical bradycardia.

Adenosine

AV nodal blocker (purinergic)

Indications: Stable regular narrow-complex tachycardia; diagnostic in stable regular monomorphic wide-complex tachycardia.
Adult dose: 6 mg rapid IV push with immediate 20 mL flush; if no effect 12 mg (AHA: may repeat 12 mg once; ERC: then 18 mg).
Preparation (India): 6 mg/2 mL vials. Use a large antecubital vein and a three-way tap for push-flush.
Cautions: Avoid in asthma/severe bronchospasm, pre-excited AF, irregular or polymorphic wide-complex tachycardia. Reduce to 3 mg with central line, heart transplant, or dipyridamole/carbamazepine.

Magnesium sulfate

Electrolyte / antiarrhythmic

Indications: Torsades de pointes; documented hypomagnesaemia. Not routine in cardiac arrest.
Adult dose: Torsades: 2 g IV over 1-2 min (arrest) or over 10-15 min (with pulse); may repeat once; then infusion 0.5-1 g/h if recurrent.
Preparation (India): 50% solution, 1 g in 2 mL ampoules (≈ 4 mmol Mg per g). 2 g = 4 mL; dilute in 10-20 mL NS for bolus.
Cautions: Hypotension, flushing; caution in renal failure.

Calcium gluconate 10% (or calcium chloride 10%)

Electrolyte

Indications: Cardiac arrest from hyperkalaemia, hypocalcaemia or calcium-channel-blocker overdose. NOT routine in arrest.
Adult dose: Calcium gluconate 10% 30 mL IV (≈ 6.8 mmol Ca), or calcium chloride 10% 10 mL (≈ 6.8 mmol); repeat as needed.
Preparation (India): Calcium gluconate 10% 10 mL ampoules are widely available; calcium chloride is less commonly stocked.
Cautions: Do not give through the same line as bicarbonate (precipitates). Tissue necrosis with extravasation (especially chloride).

Sodium bicarbonate

Alkalinising agent

Indications: Arrest due to hyperkalaemia or tricyclic/sodium-channel-blocker overdose. NOT routine in arrest.
Adult dose: 50 mmol IV (≈ 50 mL of 8.4% or ≈ 56 mL of 7.5%), repeat according to blood gas.
Preparation (India): 7.5% (0.89 mmol/mL) and 8.4% (1 mmol/mL) 10 mL and 25 mL ampoules are both sold in India; check which you have.
Cautions: Hypernatraemia, CO2 generation (ensure ventilation), inactivates catecholamines in the same line.

Alteplase

Fibrinolytic

Indications: Cardiac arrest with suspected or confirmed massive pulmonary embolism.
Adult dose: Arrest from PE: 50 mg IV bolus (ERC); consider a further 50 mg after 15 min; continue CPR for 60-90 min after thrombolysis.
Preparation (India): 50 mg vials (Actilyse). Expensive; tenecteplase is often more available in Indian emergency departments.
Cautions: Bleeding. Do not stop CPR early after giving a fibrinolytic.

Tenecteplase

Fibrinolytic

Indications: Alternative fibrinolytic for PE-related arrest when alteplase is unavailable (off-label for PE in many countries).
Adult dose: Weight-based single bolus as for STEMI: < 60 kg 30 mg; 60-69 kg 35 mg; 70-79 kg 40 mg; 80-89 kg 45 mg; ≥ 90 kg 50 mg.
Preparation (India): 20 mg, 30 mg and 40 mg vials are marketed in India (including biosimilars).

Noradrenaline (norepinephrine)

Vasopressor

Indications: Post-ROSC hypotension (MAP < 65 mmHg) after correcting volume.
Adult dose: 0.05-0.5 mcg/kg/min titrated to MAP ≥ 65 mmHg.
Preparation (India): 4 mg in 50 mL (80 mcg/mL).

Dobutamine

Inotrope

Indications: Post-arrest myocardial dysfunction with low cardiac output.
Adult dose: 2.5-10 mcg/kg/min.
Preparation (India): 250 mg in 50 mL (5000 mcg/mL).

7 topics

Recognition and high-quality CPR

ALS: shockable rhythms (VF / pulseless VT)

ALS: PEA, asystole and the reversible causes (Hs and Ts)

Peri-arrest rhythms: unstable tachycardia and bradycardia

Post-ROSC care: the first hours

Temperature control after cardiac arrest

Neuroprognostication after cardiac arrest

Drugs in this module

Module references (19)