After Return of Spontaneous Circulation (ROSC) in a cardiac arrest victim, the following sequence should occur:

  1. Assure oxygenation beginning at a breath every 5-6 seconds.
  2. If waveform capnography is available, titrate the oxygen and ventilation to a PETCO2 of 35-40 mm Hg.
  3. If waveform capnography is not available, titrate oxygenation to an oxygen saturation >94%.
  4. If an IV is not in place, establish one.
  5. Treat a systolic blood pressure < 90 mm Hg.
    1. Give 1 to 2 liters of IV fluids (saline or lactated Ringer’s solution) quickly.
    2. Give Epinephrine infusion to keep the SBP > 90 mmHg.
    3. May give Dopamine IV infusion
    4. May give norepinephrine in cases of extremely low SBP.
  6. Evaluate the H’s and T’s for treatable causes:
  1. Hypovolemia –Treatment includes infusion of saline or lactated Ringer’s solution.
  2. Hypoxia –Treatment should include airway management and effective ventilation and oxygenation.
  3. Hydrogen Ion excess (Acidosis) –Treatment should include hyperventilation and bolus of sodium bicarbonate.
  4. Hypoglycemia –Treatment includes bolus of dextrose.
  5. Hypokalemia – Treatment may include infusion of potassium.
  6. Hyperkalemia – Treatment may include calcium chloride, sodium bicarbonate, and glucose with insulin.
  7. Hypothermia – Treatment should include rewarming.
  8. Tension Pneumothorax – Treatment will include needle decompression or thoracostomy.
  9. Tamponade (Cardiac) – Treatment will be pericardiocentesis by experienced team member.
  10. Toxins – Treatment will be based on the specific overdose.
  11. Thrombosis (pulmonary embolus) – Treatment may include fibrinolytics or surgical embolectomy.
  12. Thrombosis (acute MI) – Consult cardiology.
  1. Evaluate the level of consciousness.
    1. If the patient does not follow commands, consider inducing hypothermia.
    2. If the patient does follow commands, or after inducing hypothermia, obtain a 12 lead ECG to determine if ST segment elevation myocardial infarction (STEMI) or acute myocardial infarction (AMI) has occurred.
  2. If STEMI or AMI is suspected, transfer to a facility able to perform Percutaneous Coronary Intervention (PCI) to perfuse the coronary arteries.
  3. When AMI is not suspected, or after PCI, transfer to an Intensive Care Unit for advanced critical care.
Summaries created by:
 Acls Certification Institute
Adult Immediate Post Cardiac Arrest Care