Cardiovascular · Topic 24 of 48

Post-Cardiac Arrest Care

Cardiovascular · after ROSC

Post-Cardiac Arrest Care

After ROSC, protect brain and heart: MAP ≥ 65, SpO₂ 90–98%, temperature 32–37.5 °C, cath for ST elevation, and wait 72 hours to prognosticate.

Key numbers

Keep MAP at least 65 mmHgMAP ≥ 65 mmHg

Titrate oxygen to SpO₂ 90–98%SpO₂ 90–98%

Temperature 32–37.5 °C for ≥ 36 h32–37.5 °C, ≥ 36 h

Prognosticate at least 72 hours after normothermia≥ 72 h

Keep PaCO₂ 35–45 mmHgPaCO₂ 35–45

01 · The numberKeep MAP at least 65 mmHg

Avoid hypotension after ROSC by keeping MAP at least 65 mmHg with fluids and vasopressors as needed; no specific vasopressor is preferred.

02 · DoTemperature 32–37.5 °C for ≥ 36 h

Every adult not following verbal commands after ROSC, whatever the rhythm or location, gets a deliberate, protocolized temperature-control strategy holding 32–37.5 °C for at least 36 hours.

03 · The rulePrognosticate at least 72 hours after normothermia

Neuroprognostication is multimodal, never based on a single finding, and consolidated at least 72 hours after normothermia and stopping sedatives — about 5 days after ROSC when a hypothermic target was used.

Presentation

What you'll see

Poor-outcome signs only count combinedWith other tests, poor-outcome signs include bilaterally absent pupillary or corneal reflexes at ≥ 72 h, absent N20 SSEP waves at ≥ 48 h, and high NSE or neurofilament light within 72 h.

Diagnosis & monitoring

Work-up

Titrate oxygen to SpO₂ 90–98% must knowGive 100% FiO₂ until SpO₂ or PaO₂ can be measured reliably, then titrate to SpO₂ 90–98% (PaO₂ 60–105 mmHg), avoiding both hypoxemia and hyperoxemia.

Keep PaCO₂ 35–45 mmHgVentilate comatose patients to a normal PaCO₂ of 35–45 mmHg unless severe acidemia is present, and confirm with an arterial blood gas.

Keep glucose 70–180 mg/dLAvoid both hypoglycemia (glucose below 70 mg/dL) and hyperglycemia (above 180 mg/dL) after ROSC.

Do right now

In this order

First moves

Titrate oxygen to SpO₂ 90–98%SpO₂ 90–98%

→

Keep MAP at least 65 mmHgMAP ≥ 65 mmHg

→

12-lead ECG as soon as possible after ROSC

→

Emergent cath for ST elevation after ROSC

→

Temperature 32–37.5 °C for ≥ 36 h32–37.5 °C, ≥ 36 h

Why each step

Titrate oxygen to SpO₂ 90–98%Give 100% FiO₂ until SpO₂ or PaO₂ can be measured reliably, then titrate to SpO₂ 90–98% (PaO₂ 60–105 mmHg), avoiding both hypoxemia and hyperoxemia.

Keep MAP at least 65 mmHgAvoid hypotension after ROSC by keeping MAP at least 65 mmHg with fluids and vasopressors as needed; no specific vasopressor is preferred.

12-lead ECG as soon as possible after ROSCObtain a 12-lead ECG as soon as feasible after ROSC; head-to-pelvis CT and echocardiography or POCUS may be reasonable to find the cause of arrest and resuscitation injuries.

Emergent cath for ST elevation after ROSCPerform emergency coronary angiography when a cardiac cause is suspected and the ECG shows persistent ST elevation, regardless of coma; it is also reasonable for cardiogenic shock, recurrent ventricular arrhythmias or ongoing ischemia.

Temperature 32–37.5 °C for ≥ 36 hEvery adult not following verbal commands after ROSC, whatever the rhythm or location, gets a deliberate, protocolized temperature-control strategy holding 32–37.5 °C for at least 36 hours.

Management

Orders

EEG for patients not following commandsSeizures occur in 10–35% of patients not following commands: obtain EEG promptly (repeated or continuous), treat clinical and EEG-only seizures, and do not give routine seizure prophylaxis.

Rewarm no faster than 0.5 °C per hourAvoid rewarming faster than 0.5 °C/hour after hypothermic temperature control or spontaneous hypothermia; whether a hypothermic or normothermic target improves outcome is unclear.

Red flags & don'ts

Avoid harm

No routine emergent cath without ST elevation avoidIn comatose patients without ST elevation, shock, electrical instability or significant ongoing ischemia, emergency angiography is not better than a delayed or selective strategy.

More detail

Reference

Show 9 reference facts

Coronary angiography before discharge is recommended for survivors with a suspected cardiac cause, especially an initial shockable rhythm, unexplained LV systolic dysfunction or severe ischemia.

With multivessel disease and shock after arrest, revascularize only the infarct-related artery initially; temporary mechanical circulatory support is not routine, only for highly selected refractory cardiogenic shock.

Withdrawal or better motor response may support a favorable prognosis; preserved pupillary or corneal reflexes alone do not.

Do not treat myoclonus that has no EEG correlate; a trial of a nonsedating antiseizure drug may be reasonable for EEG patterns on the ictal–interictal continuum.

Prophylactic antibiotics, neuroprotective agents and routine steroids for post-arrest shock are of uncertain benefit.

Pulse oximetry can overestimate saturation and conceal hypoxemia in patients with darker skin pigmentation.

Consider organ donation for every resuscitated patient who meets criteria for brain death or before planned withdrawal of life-sustaining therapy.

Before discharge, survivors need structured screening for emotional distress, multimodal rehabilitation assessment and multidisciplinary discharge planning with their caregivers.

Monitoring intracranial pressure, cerebral blood flow, brain tissue oxygen or jugular venous saturation after arrest is not of established usefulness.

Pearl

Don't call it early: neuroprognosis waits at least 72 hours after normothermia and sedation are off, and no single test decides.

Sources · 2025 AHA Guidelines for CPR and ECC — Part 11: Post-Cardiac Arrest Care · AHA 2025 ACLS algorithms poster set (JN-2788, 12/25): Adult Post–Cardiac Arrest Care Algorithm · Merck Manual Professional — Cardiopulmonary Resuscitation (CPR) in Adults (postresuscitative care) · The Hospitalist — AHA advocates normothermia for most comatose OHCA patients (2023 advisory; prior 32–36 °C for 24 h) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).