emDOCs Podcast – Episode 98: Post ROSC Mental Model

Today on the emDOCs cast Brit Long interviews Zachary Aust on the use of a mental model in post ROSC patients.

Episode 98: Post ROSC Mental Model

What’s the problem?

  • The Code
    • Whatever caused the initial arrest
    • Iatrogenic injuries from CPR
  •  Patients are in a pathophysiologic state that is being called “post-cardiac arrest syndrome”
    • Hypoxic brain injury
    • Myocardial dysfunction
    • Systemic ischemia/reperfusion injury
    • SIRS Response
  • Very fragile state
  • Hard to diagnose what is going on
  • Small Things Matter


Overview – C A B S

  • Circulation
    • Close monitoring of perfusion
    • Arterial Line
    • US/Doppler
    • Pulse Ox
    • ETCO2
    • Higher MAP with Immediate Vasopressors + Fluids
    • Norepinephrine or Epinephrine
  • Airway
    • Definitive Airway (before they leave)
    • Resus Before Intubation
    • Use Induction+Paralytic
    • Inline Waveform ETCO2
  • Breathing
    • Keep things normal (O2/CO2)
    • Be Mindful of Over-bagging
  • Stuff
    • EKG
    • Temp
    • Use a checklist to remember the little things



  • Multi Modal Perfusion Markers
    • Arterial Line
      • Femoral site preferred
      • Don’t lose focus on the resus
    • Ultrasound
      • Pulsatile carotid/femoral
      • Transition to doppler after ensuring correct vessel
        • Femoral vein pulsatile during CPR
    •  Pulse Ox
      • Persistent waveform
        • Good indicator of mechanical HR
    • End Tidal Capnography
      • Persistent elevation > 30-40
  • Check Heart Rate and Blood pressure
  • MAP Goal: 80 mm Hg
    • Consider >65 if severe myocardial dysfunction but in general higher MAP
  • Hypotension- need to find out why but empirically treat at the same time
    • Vasopressors immediately-Have at beside ready….or running during code
      • Norepinephrine is good default
      • Epi
        • Better for PE
        • Not for VTach/VFib
      • Vasopressin- especially if super acidotic
      • Dopamine-Just say no
  • RUSH Exam-find out why they are hypotensive
    • Rule Out PTX/Tamponade
    • RVD can be from code itself
    • Myocardial dysfunction from etiology or post cardiac arrest syndrome
      • Serial assessments
  • Probably 1-2 L IVF up front, don’t blindly administer massive amounts of fluid
  • Bradycardia- check BP
    • HTN- likely appropriate response, monitor closely can drop soon
    • Hypotensive- see above
      • If you think the bradycardia is driving the hypotension sure try atropine
      • But get the epi/pacing ready



  • If no ETT/definitive airway they need one….not the biggest priority (focus on circulation) but sooner rather than later…before they leave the room for sure
    • Remember it’s okay to use LMA during code but be using…
  • ETCO2 In Line Waveform
    • No ETCO2 reading? Check the pulse
  • RSI= Resuscitation Sequence Intubation
    • Hypoxia, Hypotension, and Acidosis are the reason patients code during/post intubation
    • These patients are super high risk for all 4
  • Optimize first pass success – Induction agent + paralytic
    • Unconscious patients will still have muscle tone
  • Induction
    • Ketamine or Etomidate at half doses (i.e., Ketamine 50 mg IV)
  • Paralytic-double the dose
    • Rocuronium is my choice
      • Unlikely to know true potassium given ischemia/reperfusion
  • Post Intubation analgesia/sedation
    • Patients can have awareness post ROSC
    • Also need to consider neuro prognostication
    • Short acting agents
    • Use ketamine drip if it’s an option
    • Can re-dose Ketamine/Etomidate (easy to forget however)
    • Propofol with a pressor less optimal here in the immediate period but once stabilized a good option
    • Fentanyl
      • Pushes
      • May not be ideal for drip as it can build up but okay to start while in ED if stopping before before leaving for ICU
    • Please stop using versed drips for post intubation sedation
  • NG/OG tube and HOB elevated



  • Overview
    • Target normoxia and normocapnia
    • Target a SpO2 of 92-95% (PaO2 80-150)
    • ETCO2 30-35 (PaCO2 35-45)
  •  Oxygen
    • Avoid both hypoxia and hyperoxia (remember the little things)
    • Target a SpO2 of 92-95%
    • Titrate down FiO2 to the minimum for this and as quickly as you can
    • Don’t need blood gas to do this
  •  CO2
    • Avoid hypocapnia (decreased brain perfusion)
    • Unclear if hypercapnia is beneficial, avoid until more date
    • Verify with blood gas as needed BUT remember the ETCO2 is AT LEAST what our PaCO2 is
  •  Use lung protective settings unless asthmatic/COPD
  • Over-bagging with BVM is common; will cause decrease venous return


Stuff (workup/imaging/other meds)

  • Utilize a physical checklist here
  • My preferred at this time linked in chapter above
  • POCUS-RUSH as above
  • POC Glucose
  • Broad workup
  • Basics+coags, trops, thyroid, pregnancy
  • Low threshold for sepsis add ons +abx
  • Steroids – controversial
  • CT- if unknown cause consider strongly
  • If they go I panscan for etiology and sequelae of CPR
    • CT Head
      • Some evidence that may show benefit with unknown story…I would lean towards getting one
    • CT chest-PE/dissection
      • May have clues on POCUS first
    • CT abdomen/pelvis
      • Find the source of sepsis


Targeted Temperature Management

  • My goal: Temp < 37.8 C
  • General principle of avoiding fever
  • Local guidelines will be the biggest influence
  • Evolving evidence
  • Continuous monitoring
  • Scheduled acetaminophen
  • Devices to cool depend on institution
  • Don’t over focus on this at expense of other things keep the fever down and working in conjunction with the admitting providers


Cath Lab

  • ROSC+STEMI= Cath Lab
    • AHA/ACC Class I rec
  • ROSC + No STEMI= Trend EKGs
    • 2014 AHA/ACC guidelines-patient with hemodynamic/electrical instability-
    • Immediate invasive strategy within 2 hours- Class Ia
  • Dependent on patient factors + conversation with interventional cardiology
    • Patient factors to consider
      • Witnessed or unwitnessed arrest, non shockable initial rhythm, bystander CPR, 30 min until ROSC, pH < 7.2, Lactate >7, age >85, ESRD, non cardiac causes likely
      • Be cautious using pH and Lactate in isolation without other factors


One thought on “emDOCs Podcast – Episode 98: Post ROSC Mental Model”

  1. This is a great mental model!

    I’m not sure the MAP goal should be > 80 mmHg post arrest. This is not zero risk if having to use catecholamines to achieve a higher MAP target. The latest RCT (https://www.nejm.org/doi/full/10.1056/NEJMoa2208687) demonstrates a MAP of 63 has equivalent mortality and neurologic outcomes (even in the pre-existing hypertension subgroup) to a MAP of 77.

    My goal is MAP > 65 post arrest

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