EM · Post-cardiac arrest care
Post-cardiac-arrest care
The post-ROSC bundle that determines neurological survival: the oxygen and the carbon-dioxide targets, the circulation and the reperfusion, the targeted-temperature evidence (TTM2: normothermia over hypothermia), the seizure and glucose control, the identification and treatment of the cause, the avoidance of the secondary brain injuries, and the multimodal deferred prognostication.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- The return of spontaneous circulation is not the endpoint — the post-arrest care determines the neurological outcome
- Hyperoxia and hypoxia are both harmful; titrate oxygen to a saturation of 94 to 98 percent
- Hyperventilation and hypocapnia cause cerebral vasoconstriction; aim for normocapnia
- Maintain normothermia and actively treat fever; targeted hypothermia at 33 degrees is not superior
- Prognostication is multimodal and deferred for at least 72 hours — an early pessimistic prediction is often wrong
The return of spontaneous circulation is the end of the arrest and the beginning of the post-arrest care, and the post-arrest care is what determines whether the survivor wakes neurologically intact. The resuscitated patient is, in effect, a patient with an injured brain in a recovering circulation, and the goal of the hours that follow is to optimise the oxygen delivery, to protect the brain from secondary injury, and to identify and treat the cause. The Fellowship-level understanding rests on the post-ROSC bundle — the targets for oxygen, ventilation, circulation, temperature, glucose and seizures — and on the evidence that has refined it, above all the targeted-temperature trials.[2]
The principle and the post-ROSC bundle
The injured brain after cardiac arrest is exquisitely vulnerable to a second insult, and the post-ROSC bundle is a set of targets designed to prevent one. The patient is managed in a critical-care environment, intubated and ventilated, sedated and monitored. The bundle, applied from the moment of ROSC, comprises the oxygen and the carbon-dioxide targets, a mean arterial pressure that supports the cerebral and the coronary perfusion, the control of the temperature and the seizures, the control of the glucose, and the identification and the treatment of the cause.[2][4]
References5ShowHide
- [1]Dankiewicz J, Cronberg T, Lilja G, et al. Hypothermia versus normothermia after out-of-hospital cardiac arrest (TTM2). New England Journal of Medicine, 2021.PMID 34133859
- [2]Nolan JP, Sandroni C, Cariou A, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2025: post-resuscitation care. Intensive Care Medicine, 2025.PMID 41123621
- [3]Schmidt H, Kjaergaard J, Hassager C, et al. Oxygen targets in comatose survivors of cardiac arrest (EXACT). New England Journal of Medicine, 2022.PMID 36027567
- [4]Drennan IR, Berg KM, Böttiger BW, et al. Advanced Life Support: 2025 International Liaison Committee on Resuscitation Consensus on Science with Treatment Recommendations (ILCOR CoSTR). Resuscitation, 2025.PMID 41117578
- [5]Nolan JP, Sandroni C, Cariou A, et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2025 Post-Resuscitation Care. Resuscitation, 2025.PMID 41117575