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.
At the bedside
Timed steps- 1
Airway and breathing
0-10 minIntubate if not already (RSI drugs at reduced doses; haemodynamics are fragile). Confirm with waveform capnography. Tidal volume 6-8 mL/kg PBW.
- 2
Oxygen
0-10 min100% FiO2 until SpO2 is reliable, then titrate to SpO2 92-98% (AHA: 90-98%, PaO2 60-105 mmHg). Avoid hypoxaemia and hyperoxia.
- 3
Ventilation
0-10 minNormocapnia: PaCO2 35-45 mmHg. Remember PaCO2 runs above ETCO2 after arrest; check an ABG.
- 4
Circulation
0-30 minArterial line. MAP ≥ 65 mmHg (ERC: > 65, SBP > 100). Fluids if preload-responsive, noradrenaline first-line, dobutamine for low output. Avoid hypotension.
- 5
12-lead ECG
≤ 10 minSTEMI or new LBBB with high suspicion → emergency coronary angiography.
- 6
Find the cause
0-60 minEcho; ABG, K+, glucose, troponin, lactate; CT head-to-pelvis (with CT pulmonary angiography) if no obvious cardiac cause (ERC).
- 7
Angiography without STE
DecideNot routinely emergent in stable comatose patients (COACT, TOMAHAWK). Go early if shock, electrical instability or ongoing ischaemia.
- 8
Brain protection
First hoursTemperature control (next topic); short-acting sedation; glucose 140-180 mg/dL (70-180 per AHA); head up 30°; EEG if seizures suspected or patient sedated/paralysed.
- 9
Organ support and family
OngoingLung-protective ventilation, AKI monitoring, no routine prophylactic antibiotics or steroids. Early, honest communication with family; document the arrest timeline (no-flow, low-flow).
First-line vasopressor for post-ROSC hypotension
Noradrenaline (norepinephrine)
- Dose
- 0.05-0.5 mcg/kg/min, titrate to MAP ≥ 65
- Range
- 0.02–1 mcg/kg/min
- Preparation
- Norad base 4 mg in 50 mL NS (80 mcg/mL); Indian ampoule 2 mg base/2 mL
- Worked example
- 70 kg at 0.1 mcg/kg/min = 7 mcg/min = 420 mcg/h ÷ 80 = 5.25 mL/h
Low cardiac output after ROSC
Dobutamine
- Dose
- 2.5-10 mcg/kg/min
- Preparation
- 250 mg in 50 mL (5000 mcg/mL)
- Worked example
- 70 kg at 5 mcg/kg/min = 350 mcg/min = 21 000 mcg/h ÷ 5000 = 4.2 mL/h
Post-ROSC physiological targets
| Variable | AHA 2025 | ERC-ESICM 2025 |
|---|---|---|
| SpO2 | 90-98% (PaO2 60-105 mmHg) | 94-98% |
| PaCO2 | 35-45 mmHg | Normocapnia (35-45 mmHg) |
| MAP | ≥ 65 mmHg; avoid SBP < 90 | > 60-65 mmHg; SBP > 100 mmHg |
| Glucose | 70-180 mg/dL; avoid hypoglycaemia | Avoid hypoglycaemia; insulin for hyperglycaemia |
| Temperature | 32-37.5 °C for ≥ 36 h (not following commands) | Prevent fever > 37.5 °C for ≥ 72 h |
| Seizures | Treat clinical seizures; no prophylaxis | EEG; treat seizures; no prophylaxis |
Calculators for this topic
Mean arterial pressure
(SBP + 2 × DBP) ÷ 3 (estimate; use the arterial line value when available).
Infusion rate from mcg/kg/min
Pump rate in mL/h for drugs dosed in mcg/kg/min (noradrenaline, adrenaline, dobutamine, milrinone, nitroglycerin by weight).
Predicted (ideal) body weight
ARDSNet predicted body weight from height and sex. Use for tidal volume, not for most drug doses.
References
- 1
- 2
- 3
- 4
- 5
Post-ROSC bundle
Step 1 of ~6
Airway, capnography, SpO2 92-98%, PaCO2 35-45, MAP ≥ 65
Based on Part 11: Post-Cardiac Arrest Care: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; Nolan JP, Sandroni C, Cariou A, et al. Educational use; follow local protocol.
Pathophysiology
Post-cardiac arrest syndrome has four parts: brain injury, myocardial dysfunction (stunning, recovers over 24-72 h), systemic ischaemia-reperfusion response (sepsis-like vasoplegia), and the persisting precipitating cause.
Evidence
- AHA 2025 post-cardiac arrest care: SpO2 90-98%; normocapnia; avoid SBP < 90 and MAP < 65; emergency angiography for STEMI or shock/instability; head-to-pelvis CT and echo may be reasonable; no routine prophylactic antibiotics, steroids or seizure prophylaxis; routine MCS not recommended.
- ERC-ESICM 2025: SpO2 94-98%; normocapnia; MAP > 60-65; CT including CTPA when no cardiac cause; delay angiography in absence of STE unless coronary occlusion likely.
- COACT (2019) and TOMAHAWK (2021): immediate angiography did not improve survival in resuscitated patients without STE.
- BOX (2022): MAP target 63 vs 77 mmHg and restrictive vs liberal oxygen showed no difference in death or poor neurological outcome.
Controversies
- Exact oxygen target (90-98% vs 94-98%), and whether a higher MAP benefits chronic hypertensive patients.
- Mild hypercapnia (TAME 2023, not cited here) did not help.
🇮🇳 India notes
- Cath-lab access is limited outside metros; thrombolysis (tenecteplase) is reasonable for STEMI after ROSC if PCI cannot be done within 120 min, accepting the CPR-trauma bleeding risk. Discuss with cardiology.
- CT transfer of an unstable post-ROSC patient carries real risk in Indian hospitals without transport ventilators; use echo and bedside tests first.
References
- 1
- 2
- 3
- 4
- 5
Test yourself
Module quiz · score 70% to complete the module
Previous
Peri-arrest rhythms: unstable tachycardia and bradycardia
Next
Temperature control after cardiac arrest
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.