One-Pager
Post-Cardiac Arrest Care and Temperature Control
The ROSC bundle: oxygen, ventilation and MAP targets, 12-lead and cath lab, temperature control, seizures, glucose and when to prognosticate
Download one-page PDFLetter landscape, ready to print or keep with your notes
Post-cardiac arrest care: the targets
Post-cardiac arrest care after ROSC aims to stop a second injury to the brain and heart: avoid low and high oxygen, keep CO₂ normal, keep MAP at least 65 mm Hg, get a 12-lead, control temperature in anyone who cannot follow commands, and wait at least 72 hours before judging neurologic outcome.
| Target | Goal | Notes |
|---|---|---|
| Oxygen | FiO₂ 1.0 until SpO₂ or PaO₂ is reliable, then SpO₂ 94–98% (PaO₂ 75–100) | Avoid hypoxemia and hyperoxemia; follow your unit protocol |
| Ventilation | PaCO₂ 35–45 mm Hg | Check an ABG; ETCO₂ can differ widely from PaCO₂ after arrest |
| Tidal volume | 6–8 mL/kg ideal body weight | Lung-protective |
| Blood pressure | MAP at least 65 mm Hg | Higher for chronic hypertension, raised ICP or ongoing hypoperfusion |
| Temperature | 32–37.5 °C, at least 36 h | For patients who do not follow commands; prevent fever |
| Glucose | About 140–180 mg/dL | Avoid hypoglycemia; no tight control |
ROSC bundle: the first hour
- Airway: intubate if comatose; confirm with waveform capnography.
- Breathing: full oxygen until a reliable SpO₂ or ABG, then titrate down; normal PaCO₂.
- Circulation: arterial line, fluids and vasopressors to MAP 65 or more; norepinephrine is the usual first choice.
- 12-lead ECG as soon as possible after ROSC; look for ST elevation.
- Find the cause: ABG and electrolytes, echo or POCUS, and CT (head, chest, pulmonary angiogram) when no cardiac cause is clear.
- Temperature: continuous core probe (esophageal or bladder); start temperature control if not following commands.
- Neuro: exam off sedation when possible, EEG if comatose, short-acting sedation.
12-lead and the cath lab decision
| ECG after ROSC | Plan |
|---|---|
| ST elevation | Immediate coronary angiography and PCI, even if comatose |
| No ST elevation, unstable or likely coronary cause | Early angiography if no non-cardiac cause and there is shock or recurrent arrhythmia |
| No ST elevation, stable | Not routinely emergent; decide case by case after stabilizing |
Temperature control after cardiac arrest
Targeted temperature management is now called temperature control. Anyone who does not follow commands after ROSC gets it, whatever the rhythm or location of the arrest: a constant temperature between 32 and 37.5 °C for at least 36 hours, with active fever prevention afterward.
- Use a device with temperature feedback and a continuous core probe (esophageal or bladder).
- Do not actively warm a patient who is mildly hypothermic after ROSC.
- No rapid cold IV fluid boluses in the field.
- If cooled below normal, rewarm slowly and delay rewarming with instability, raised ICP, severe hyperkalemia or ongoing seizures.
- Expect and treat shivering; cooling often slows the heart rate, which is usually fine if perfusion holds.
Seizures, glucose and sedation
- EEG for every patient who stays comatose: seizures, including nonconvulsive status, occur in about 10–35%.
- Treat clinical seizures and EEG seizures promptly; no prophylactic antiseizure drugs.
- Myoclonus needs an EEG before treatment: not all of it is epileptic. Shivering can look like seizure activity.
- Glucose about 140–180 mg/dL with an insulin infusion if needed; expect insulin needs to fall during rewarming.
- Short-acting sedation (propofol, remifentanil) so the neuro exam can be done early.
Neuroprognostication: when and how
Do not predict a poor outcome early. Wait at least 72 hours after ROSC (after rewarming if cooled below normal), clear sedatives, paralytics and metabolic confounders, and use several tests together.
| Predictor of poor outcome | Timing |
|---|---|
| No pupillary and corneal reflexes | 72 h or later |
| Both N20 SSEP responses absent | 24 h or later |
| Highly malignant EEG (suppression, burst-suppression) | 24 h or later |
| NSE above 60 mcg/L | 48 and/or 72 h |
| Status myoclonus (30 min or more) | Within 72 h |
| Diffuse anoxic injury on CT or MRI | CT any time; MRI 2–7 days |
In depth
The one-page summary above is what the PDF prints. These sections go further.
Post-cardiac arrest syndrome
After the whole body has been without flow and then reperfused, four problems overlap: hypoxic-ischemic brain injury, myocardial dysfunction (common, and usually starting to recover by 2–3 days), a sepsis-like systemic ischemia-reperfusion response with vasoplegia, and whatever caused the arrest. Brain injury is the most common cause of death after ROSC, most often through withdrawal of life support, which is why early prognosis must be cautious.
Oxygen and ventilation evidence
- Right after ROSC, use the highest available FiO₂ until saturation can be measured reliably. EXACT, which lowered the early prehospital target to 90–94%, saw more hypoxemia.
- BOX found no benefit from a lower PaO₂ target (68–75 mm Hg) in comatose patients.
- TAME found no benefit from mild hypercapnia over normocapnia; normal PaCO₂ is the target.
- During hypothermic control, check PaCO₂ often and use temperature-corrected or uncorrected gases consistently, as your lab does.
Hemodynamics after ROSC
- Every patient needs an arterial line; add cardiac output monitoring (echo, PA catheter or transpulmonary thermodilution) if unstable.
- Restore MAP with fluids and vasopressors before adding an inotrope; no vasopressor has proven superior.
- A bradycardia under 30–40/min during cooling can be left alone if perfusion is adequate.
- Cardiogenic shock that persists despite drugs may need mechanical support; see the cardiogenic section of Shock Types at a Glance.
Temperature control trials
| Trial or source | What it showed |
|---|---|
| TTM1 (2013) | 33 °C vs 36 °C for 24 h: no difference |
| HYPERION (2019) | Nonshockable rhythms: 33 °C better neurologic outcome than 37 °C |
| TTM2 (2021) | 33 °C vs normothermia with early fever treatment: no difference |
| Fever prevention 36 vs 72 h | No difference in 90-day survival or neurologic outcome |
The current guidance allows any constant target from 32 to 37.5 °C. Some experts still favor 32–34 °C for the most brain-injured patients, especially after long, unwitnessed arrests, because the trial populations had mostly shockable, witnessed arrests.
Nursing care during temperature control
- Core temperature continuously; skin checks under pads every shift.
- Shivering raises oxygen use and can look like seizure activity; treat it per protocol (IV magnesium is one option) and get an EEG for any new movement.
- Cooling: cold diuresis and shifts lower potassium. Rewarming: potassium rebounds and insulin sensitivity rises, so glucose can fall.
- Some centers keep sodium at 140–145 mmol/L and potassium at 4.0–4.5 mmol/L (tolerating 3.0–3.5 while cooled to avoid rebound).
- Early trophic tube feeding, DVT prophylaxis, and stress ulcer prophylaxis if anticoagulated or coagulopathic.
- Family updates: explain that outcome cannot be judged in the first days.
Favorable signs and outcome talk
- Signs that recovery is likely: localizing or withdrawing to pain (GCS motor 4–5) at 72–96 h, a continuous normal-voltage EEG within 72 h, NSE 17 mcg/L or less at 24–72 h, and no diffusion changes on MRI at 2–7 days.
- With neither good nor bad signs, outcome is indeterminate: keep observing and examining.
- Neurofilament light and GFAP are promising early markers, but thresholds are not standardized.
Exam pearls
- STEMI after ROSC: cath lab even if comatose.
- Comatose after ROSC: temperature control 32–37.5 °C, prevent fever.
- SpO₂ 100% after the first measurement is not the goal; titrate down.
- Hyperventilating to a PaCO₂ of 25–30 is wrong.
- A single bad finding at 24 h is not enough to predict outcome.
- Myoclonus without EEG correlate: do not treat as status epilepticus.
Practice free in your browser3,800+ exam-style questions with rationales. No account, no ads. Also free on the App Store and Google Play.
Related one-pagers
- Hemodynamic NormalsNormal adult values, key formulas and how to read the waveforms behind them
- Shock Types at a GlanceHemodynamic patterns, exam findings and first treatments for each shock type
- Vasopressors and InotropesReceptors, doses, SSC 2026 septic shock order, push-dose pressors and extravasation
- ACS and STEMITerritories, time goals, first drugs and complications
- Heart FailureHFrEF vs HFpEF, stages, GDMT pillars, warm/cold profiles, shock and diuretics
- Right Heart Failure and Pulmonary HypertensionRV physiology, recognition, PH groups, ICU causes, drugs, intubation risk and mechanical support
Sources
- ILCOR Advanced Life Support Task Force. Oxygen and carbon dioxide targets in patients with return of spontaneous circulation after cardiac arrest (2025 CoSTR, draft for public comment). Link
- Chia YW, Pothiawala S, Loh JK, Leong CK, et al. Singapore Post-cardiac Arrest Care Guidelines 2026. Singapore Med J. 2026;67(7):427–441. Link
- Bang HJ, Youn CS, Kim MC, Lim Y, et al. 2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 6. Post-cardiac arrest care. Clin Exp Emerg Med. 2026;13(Suppl 1):S75–S100. Link
- Nolan JP, Sandroni C, Böttiger BW, Cariou A, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med. 2021;47:369–421. Link
- European Society for Emergency Medicine and European Society of Anaesthesiology and Intensive Care. Temperature control after successful resuscitation from cardiac arrest in adults: a joint statement. Eur J Anaesthesiol. 2024;41:278–281. Link