Post-Resuscitation Care

Airway & breathing

• Confirm advanced airway position and use continuous waveform capnography where available
• Oxygen: use 100% inspired oxygen until SpO₂ or PaO₂ can be measured reliably
  • Once reliable measurement is available, titrate FiO₂ to SpO₂ 90–98% (PaO₂ 60–105 mmHg)
  • Avoid both hypoxemia and hyperoxemia; do not leave the patient on FiO₂ 1.0 indefinitely without an indication
  • Pulse oximetry may be unreliable with poor perfusion and may conceal hypoxemia in darker skin; confirm with an ABG when needed (oxygen desaturation)
• Ventilation: target normocapnia, generally PaCO₂ 35–45 mmHg, in patients who remain comatose
  • Obtain an ABG after stabilization and adjust ventilation accordingly
  • Avoid hyperventilation and hypocapnia
  • Individualize PaCO₂ only where there is a specific reason to

Hemodynamics

• Avoid hypotension. Target MAP ≥ 65 mmHg as the general minimum
• Individualize a higher MAP target to premorbid blood pressure, cerebral perfusion concerns, cardiogenic shock and overall physiology
• Assess volume status; give measured IV fluid boluses where depleted, then start vasoactive support early if hypotension persists
  • Norepinephrine is a reasonable practical first choice in most post-arrest shock states
  • AHA 2025 found insufficient evidence to recommend a specific vasopressor; match therapy to the shock phenotype
• Consider invasive arterial blood pressure monitoring in unstable patients

Access & monitoring

• Secure reliable IV access; IO access is acceptable when IV access is not immediately available
• Replace contaminated or temporary emergency access when clinically appropriate
• Insert central venous access only when needed: ongoing vasoactive therapy, difficult access, or another clinical indication; not routine for every patient
• Continuous cardiac monitoring; head of bed at 30°
• Urinary catheter; consider a gastric tube in the unconscious patient

• ROSC tells you the circulation returned. It does not tell you why the patient arrested. Keep looking systematically.

Cardiac

• Acute coronary occlusion / ACS
• Ventricular arrhythmia
• Cardiomyopathy and acute LV failure
• Mechanical complications where relevant

Pulmonary

• Pulmonary embolism
• Hypoxemic or hypercapnic respiratory failure
• Pneumonia
• Airway obstruction or mucus plugging
• Tension pneumothorax

Neurological

• Intracranial hemorrhage
• Subarachnoid hemorrhage
• Other acute catastrophic neurological event
• Seizure or status epilepticus

Metabolic & toxicological

• Hyperkalemia and severe electrolyte disturbance
• Acidosis from a specific underlying process
• Drug or toxin exposure
• Dialysis-related and other metabolic derangement
• Continue to work through the reversible Hs & Ts

Emergency coronary angiography

• Perform emergently where there is a suspected cardiac cause and persistent ST-segment elevation, regardless of coma
• Reasonable without ST elevation in selected patients with a suspected cardiac cause and any of:
  • Cardiogenic shock
  • Recurrent ventricular arrhythmias
  • Evidence of significant ongoing myocardial ischemia
• Stable comatose patients without ST elevation, shock, recurrent electrical instability or ongoing ischemia: routine immediate angiography is not recommended over a delayed or selective approach
• Angiography before discharge for survivors with a suspected cardiac cause, particularly initial shockable rhythm, unexplained LV systolic dysfunction or severe ischemia

ECG

• Obtain a 12-lead ECG immediately: STEMI or STEMI-equivalent, arrhythmia, QTc, signs of PE

• Avoid hypoxemia, hyperoxemia, hypotension and hypocapnia
• Treat seizures
• Use protocolized temperature control
• Avoid premature neurological prognostication

Temperature control

• All adults still unresponsive to verbal commands after ROSC: deliberate protocolized temperature-control strategy, whatever the arrest location or rhythm
• Maintain temperature between 32 °C and 37.5 °C according to the selected strategy and local protocol
• Continue protocolized temperature control for at least 36 hours
• Actively prevent fever (≤ 37.5 °C) for 36–72 hours according to local protocol
• Avoid rapid rewarming, faster than 0.5 °C per hour
• Do not use routine rapid infusion of large volumes of cold IV crystalloid solely to induce hypothermia
• Deep hypothermia has not beaten controlled normothermia with fever prevention for all patients; 33 °C remains within the accepted range, but is no longer the default for everyone

Seizures, myoclonus & EEG

• Obtain a prompt EEG in patients who do not follow commands after ROSC
• Treat clinical and electrographic seizures; do not use routine seizure prophylaxis
• Suppressing myoclonus that has no EEG correlate is not recommended
• Post-arrest myoclonus alone does not establish a hopeless neurological prognosis
• Do not use any single EEG finding, outside the correct timing and context, as an isolated prognostic test

• This is a baseline assessment to guide care and detect complications. It is not early prognostication.

Laboratory

• Initial investigations may include: CBC, renal profile, electrolytes including potassium, magnesium and calcium, glucose, lactate, ABG or VBG, coagulation profile
• Troponin where clinically indicated
• Toxicology testing when appropriate
• Additional targeted investigations based on the suspected cause
• Trend abnormal parameters according to the patient’s physiology and clinical context rather than a fixed universal schedule

Post-arrest acidosis

• Metabolic and lactic acidosis is common after ROSC and usually reflects preceding low-flow physiology and reperfusion
• Management is restoring perfusion, appropriate ventilation, treating shock and correcting the underlying cause
• Do not give sodium bicarbonate solely because the post-ROSC pH is low
• Bicarbonate only for a specific indication: severe hyperkalemia, sodium-channel blocker toxicity, or another clearly defined toxicological or metabolic indication

Imaging

• Chest radiograph where clinically appropriate: tube and line position, pulmonary pathology, pneumothorax
• Bedside echocardiography / POCUS: ventricular function, RV strain, pericardial effusion, volume status
• CT head when a primary neurological cause is suspected or neurological findings warrant it
• Consider broader imaging, including head-to-pelvis CT, particularly where the cause remains uncertain or complications of resuscitation are suspected
• Individualize the imaging strategy to the suspected diagnosis and hemodynamic stability

Aspiration

• Evaluate for aspiration after cardiac arrest
• Aspiration pneumonitis alone does not require antibiotics
• Start antibiotics when aspiration pneumonia or another bacterial infection is clinically suspected

Ongoing monitoring

• Continuous cardiac and temperature monitoring
• Glucose: avoid hypoglycemia (< 3.9 mmol/L) and values > 10 mmol/L; a target of 7.8–10 mmol/L is reasonable under the local ICU protocol
• EEG where indicated, as above

Neuroprognostication

• Do not use the neurological examination immediately after ROSC to make a definitive prognosis.
• Formal prognostication must be delayed until confounders are addressed: sedation, neuromuscular blockade, temperature management, shock and metabolic abnormalities
• Use a multimodal assessment. Never rely on a single sign or test
• Consolidate multimodal assessment at a minimum of 72 hours after return to normothermia and discontinuation of sedatives
• Where hypothermia was used, defer assessment until approximately 72 hours after rewarming
• Hold early, regular and transparent multidisciplinary discussions with families about the expected time course and the uncertainty involved

Family communication

• Communicate early with family and surrogates
• Explain that the patient remains critically ill despite restoration of circulation
• Be explicit about uncertainty regarding both the cause and neurological recovery
• Avoid definitive neurological predictions in the early post-arrest period
• Reassess and communicate evolving information over time

Updated to AHA 2025 and ERC/ESICM 2025 guidance. Educational reference for doctors in training; always cross-check current local policy.