START: ROSC Achieved
Return of spontaneous circulation after cardiac arrest
All Pathways
Emergency MedicineEmergency
Post-ROSC Care (AHA 2025)
Post-ROSC Care (AHA 2025): START: ROSC Achieved → Immediate Post-ROSC → STEMI or High Suspicion for ACS? → Emergent Coronary Angiography → Hemodynamic O...
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Action Immediate Post-ROSC
Stabilization
- Secure airway if not done (ETT preferred)
- Verify ETT placement (capnography)
- Obtain 12-lead ECG immediately
- Establish IV access, labs (troponin, lactate, ABG)
- Continuous monitoring
03Decision STEMI or High Suspicion for ACS?
Evaluate for coronary intervention
- STEMI on ECG: Emergent cath
- No STEMI but suspected cardiac etiology: Consider early cath
- Non-cardiac etiology (PE, overdose, trauma): Treat cause
04Action Emergent Coronary Angiography
Do not delay for comatose patients
- Immediate cath for STEMI
- Early cath (within 24h) for non-STEMI with suspected ACS
- Coma is NOT a contraindication
- PCI as indicated
05Action Hemodynamic Optimization
Avoid hypotension
- Target SBP ≥90 mmHg, MAP ≥65 mmHg
- Fluids if hypovolemic
- Vasopressors: Norepinephrine or Epinephrine infusion
- Consider inotropes if cardiogenic shock
- Consider ECMO/Impella for refractory shock
06Action Ventilation & Oxygenation
Avoid extremes
- Target SpO2 92-98% (avoid hyperoxia)
- Target PaCO2 35-45 mmHg (avoid hypo/hypercapnia)
- Lung-protective ventilation
- Avoid hyperventilation
07Action Targeted Temperature Management
TTM for comatose patients
- TTM if comatose (not following commands)
- Target 32-36°C for at least 24 hours (TTM2: 33°C vs 36°C equivalent)
- Prevent fever (>37.7°C) for at least 72 hours
- Active warming to avoid shivering
- Continuous temperature monitoring
08Action Seizure Management
Treat clinical seizures
- Continuous EEG monitoring if comatose
- Treat clinical seizures aggressively
- Levetiracetam or valproate first-line
- Prophylactic antiseizure drugs NOT recommended
09Action Neuroprognostication
Multimodal assessment at ≥72 hours
- Wait ≥72 hours after ROSC (or after rewarming)
- Wait for confounders to clear (sedation, paralysis)
- MULTIMODAL approach: Clinical exam, EEG, SSEP, MRI, biomarkers (NSE)
- No single test is sufficient
- Involve palliative care early
10Outcome Favorable Prognosis
Continue supportive care
- Continue ICU care
- Wean sedation
- Early rehabilitation
- ICD evaluation if indicated
11Outcome Poor Prognosis
Goals of care discussion
- Family meeting with multidisciplinary team
- Consider organ donation
- Palliative care involvement
- Avoid premature WLST
12Action Glucose & Other Care
Supportive measures
- Avoid hypoglycemia (<70 mg/dL)
- Avoid hyperglycemia (target 140-180 mg/dL)
- Stress ulcer prophylaxis
- DVT prophylaxis
- Path rejoins step 09Shared downstream outcome
- Path rejoins step 05Shared downstream outcome
Guideline Source
AHA 2025 Guidelines Part 11: Post-Cardiac Arrest Care
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- TTM parameters still evolving
- Cath lab availability varies
- Neuroprognostication requires multimodal approach
- Applies to adult cardiac arrest
Contraindicated Populations
pediatric
Applicable Regions
USEUGlobal
US: AHA 2025 is current standard
Version 1Next review: 2028-01-01
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Related Resources
Frequently Asked Questions
What is the Post-ROSC Care (AHA 2025)?
The Post-ROSC Care (AHA 2025) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on AHA 2025 Guidelines Part 11: Post-Cardiac Arrest Care.
What guideline is the Post-ROSC Care (AHA 2025) based on?
This algorithm is based on AHA 2025 Guidelines Part 11: Post-Cardiac Arrest Care (DOI: 10.1161/CIR.0000000000001375).
What are the limitations of the Post-ROSC Care (AHA 2025)?
Known limitations include: TTM parameters still evolving; Cath lab availability varies; Neuroprognostication requires multimodal approach; Applies to adult cardiac arrest. Individual patient factors may require deviation from these recommendations.
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