Cardiac Arrest & Post-ROSC CareICU / resuscitation

Critical Care / ICU · Ward Pathways · Free — no sign-in

Collapse, pulseless — start the clockwork: quality CPR, adrenaline every 3–5 min, shock the shockable, hunt Hs & Ts, then protect the brain after ROSC.

ABCDE

High-quality CPR 100–120/min, 5–6 cm depth, minimal pauses; adrenaline 1 mg IV q3–5 min; defibrillate VF/pVT at 200 J biphasic; reversible causes in parallel.

  1. CPR quality first: 100–120 compressions/min, depth 5–6 cm, full recoil, rotate compressors q2 min, <10 s pauses; waveform capnography (ETCO₂ >10 mmHg = adequate)
  2. Shockable (VF/pVT): shock 200 J biphasic → CPR 2 min → shock; adrenaline 1 mg after initial defibrillation attempts have failed (typically after 2nd–3rd shock), then q3–5 min; amiodarone 300 mg after 3rd shock (or lidocaine 100 mg as alternative)
  3. Non-shockable (PEA/asystole): adrenaline 1 mg IV/IO as early as possible then q3–5 min; no shocks — hunt causes
  4. Reversible causes (Hs & Ts): hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis (MI/PE) — treat in parallel, not after
  5. ROSC → 12-lead within minutes: STEMI or high suspicion → cath lab activation even if comatose; no STEMI → CT head/chest as indicated
  6. Post-ROSC bundle: SpO₂ 90–98% (avoid hyperoxia AND hypoxaemia), normocapnia, MAP ≥65, temperature control 32–37.5 °C for comatose survivors maintained ≥36 h (prevent hyperthermia), glucose 8–10 mmol/L, ICU (2025 AHA)
Calculators:

Order set

  • Adrenaline 1 mg IV/IO q3–5 min
  • Amiodarone 300 mg (shock-refractory VF/pVT)
  • Defibrillator pads before arrival if possible
  • Waveform capnography
  • ABG + K⁺/glucose during arrest
  • 12-lead ECG immediately post-ROSC
  • Temperature control 32–37.5 °C (comatose survivors, ≥36 h)
  • Cath lab activation if STEMI

Monitor

  • Peri-arrestETCO₂ (fall predicts loss of output; rise predicts ROSC)
  • Post-ROSC q15 minMAP, SpO₂, ETCO₂-PaCO₂ gradient
  • ContinuousTemperature probe — prevent fever ≥72 h
  • ≥72 hMultimodal neuroprognostication — never earlier

Escalate / ICU

  • ETCO₂ <10 after 20 min quality CPR (prognosis grave)
  • Refractory arrest with reversible cause → E-CPR centre (reasonable, COR 2a — 2025 AHA)
  • Any ROSC → ICU
  • Post-ROSC seizures → EEG + treat as status

Criteria

Adrenaline1 mg q3–5 min; early in non-shockable
Amiodarone300 mg after 3rd shock (150 mg after 5th)
Cath labSTEMI (or shock/refractory ventricular arrhythmia/ongoing ischaemia) post-ROSC regardless of coma; not routine for comatose non-STEMI
PrognosticateNot before 72 h, multimodal only

Never

  • Hyperoxia after ROSC — titrate O₂ down to SpO₂ 90–98%
  • Vasopressin — no role in cardiac arrest (2025 AHA)
  • Routine immediate cath for comatose non-STEMI (COACT/TOMAHAWK) — emergent cath only for STEMI/shock/refractory ventricular arrhythmia/ongoing ischaemia
  • Give routine sodium bicarbonate or calcium
  • Stop to check pulses mid-cycle for >10 s
  • Prognosticate in the first 72 h — sedation and TTM confound everything

Key

  • ETCO₂ is your CPR quality gauge — <10 mmHg means push harder/rotate
  • Adrenaline + amiodarone (or lidocaine alternative) are the antiarrhythmic/evidence drugs in arrest; vasopressin has no role
  • Post-ROSC hypotension (SBP <90) doubles mortality — noradrenaline early
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
  • Witnessed vs unwitnessed + downtime
  • ETCO₂ <10 despite quality CPR
  • Post-ROSC papilloedema/fixed pupils (do not act early)
  • Recurrent VF — overdrive pacing/ischaemia
Differentials
  • Acute MI (commonest)
  • PE — thrombolyse intra-arrest if suspected
  • Hyperkalaemia (dialysis patient, peaked T)
  • Toxins: β-blocker, CCB, tricyclic, local anaesthetic (lipid)
Common mistakes
  • Freon-style interruptions for intubation
  • Delaying access — IV is first choice (COR 1); IO reasonable if IV unsuccessful/not feasible (COR 2a, 2025 AHA)
  • Hypoglycaemia missed as cause
  • Early withdrawal discussions before 72 h
Disposition & follow-up

All ROSC → ICU; coronary angiography if STEMI or unstable; daily sedation holds from 48–72 h for neuro assessment; family communication early and honest.

💊 Treatment detail — doses & preparation
Adrenaline 1 mg (arrest)ACLS
Dose1 mg IV/IO every 3–5 min during arrest
Preparation1 mL of 1:10,000 (0.1 mg/mL) = 1 mg in 10 mL pre-filled syringe; flush 20 mL after
MonitorETCO₂ response; give early in non-shockable rhythms
Amiodarone IVantiarrhythmic
DoseArrest: 300 mg IV/IO bolus (then 150 mg). Stable: 150 mg over 10 min, then 1 mg/min ×6 h, 0.5 mg/min ×18 h
PreparationBolus 300 mg in 20–50 mL D5W; infusion 900 mg in 500 mL D5W (glass/non-PVC)
MonitorQT, LFTs, thyroid; long half-life — interacts with warfarin/digoxin
Noradrenaline (norepinephrine)vasopressor
Dose0.05–1 mcg/kg/min IV infusion, titrate to MAP ≥65
Preparation4 mg in 250 mL D5W or NS (16 mcg/mL) via infusion pump; central line preferred — proximal peripheral vein acceptable short-term
MonitorContinuous invasive MAP; check limb perfusion, urine output; wean gradually, never stop abruptly
Calcium gluconate 10%membrane stabiliser
Dose10–30 mL of 10% IV over 2–5 min for hyperK ECG changes; repeat q10 min ×3 PRN
Preparation10 mL ampoules (2.2 mmol Ca²⁺ each), undiluted slow push with cardiac monitor
MonitorECG immediately (QRS narrows); effect 1–3 min, lasts 30–60 min — shift/remove K⁺ in parallel
Sodium bicarbonate 8.4%alkalising agent
DoseTCA: 1–2 mmol/kg IV bolus then infusion to pH 7.50–7.55. Salicylate: urine alkalinisation pH 7.5–8.5
PreparationBolus 50–100 mL of 8.4% (1 mmol/mL); infusion 150 mmol in 1 L D5W + 20–40 mmol KCl
MonitorABG, K⁺ (hypokalaemia blocks alkalinisation), ionised Ca²⁺, volume
📖 2025 AHA Guidelines for CPR & ECC / ERC ALS + textbook Ch.19–20Reviewed July 2026

← Hypertensive Emergency  ·  Acute Liver Failure →

More Critical Care / ICU pathways

Part of Critical Care / ICU in Ward Pathways — open the interactive version.

ICU Decoded — original critical-care and internal-medicine pathways by Dr Javed Akhtar, each cited to a current guideline. For education and quick reference; verify every dose against local protocols before prescribing.

Open the app · Ward Pathways — 113 free cases · ICU Decoded chapters · Aladin Chirag bedside tools

About · Medical disclaimer · Privacy · Contact