Post-ROSC Care (AHA 2025)

Algorithm Steps

1. ▶

   Start

   START: ROSC Achieved

   Return of spontaneous circulation after cardiac arrest

   1. ●

      Action

      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
      1. ◆

         Decision

         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
         1. ●

            Action

            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
            1. ●

               Action

               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
               1. ●

                  Action

                  Ventilation & Oxygenation

                  Avoid extremes

                  • Target SpO2 92-98% (avoid hyperoxia)
                  • Target PaCO2 35-45 mmHg (avoid hypo/hypercapnia)
                  • Lung-protective ventilation
                  • Avoid hyperventilation
                  1. ●

                     Action

                     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
                     1. ●

                        Action

                        Seizure Management

                        Treat clinical seizures

                        • Continuous EEG monitoring if comatose
                        • Treat clinical seizures aggressively
                        • Levetiracetam or valproate first-line
                        • Prophylactic antiseizure drugs NOT recommended
                        1. ●

                           Action

                           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
                           1. ✓

                              Outcome

                              Favorable Prognosis

                              Continue supportive care

                              • Continue ICU care
                              • Wean sedation
                              • Early rehabilitation
                              • ICD evaluation if indicated
                           2. ✓

                              Outcome

                              Poor Prognosis

                              Goals of care discussion

                              • Family meeting with multidisciplinary team
                              • Consider organ donation
                              • Palliative care involvement
                              • Avoid premature WLST
                     2. ●

                        Action

                        Glucose & Other Care

                        Supportive measures

                        • Avoid hypoglycemia (<70 mg/dL)
                        • Avoid hyperglycemia (target 140-180 mg/dL)
                        • Stress ulcer prophylaxis
                        • DVT prophylaxis