Return of spontaneous circulation (ROSC) is the resumption of sustained perfusing cardiac activity following cardiac arrest.  Regardless of the cause of the cardiac arrest, the hypoxemia, ischemia, and reperfusion that occur during cardiac arrest and resuscitation may damage multiple organ systems.  The severity of this damage can vary widely among patients, and even among organ systems within individual patients.

Effective post–cardiac arrest care consists of identification and treatment of the precipitating cause of cardiac arrest, combined with the assessment and mitigation of ischemia and reperfusion injury to multiple organ systems.  In the prehospital environment, ROSC management is oriented towards maintaining appropriate oxygenation, ventilation, and hemodynamics, while attempting to identify the precipitating cause, and initiating rapid transport to hospital for further diagnostics and interventions.

• Target oxygenation and ventilation to SpO₂ of 94-99%, and EtCO₂ of 30-40mmHg.
• Avoid hypotension.  The target systolic blood pressure is >100 mmHg (or a mean arterial pressure >65 mmHg).  Limit fluid bolus to a maximum of 20 mL/kg unless treating suspected hypovolemia.
• Allow approximately 10 minutes of perfusion before attempting to acquire a 12-lead ECG.
• Elevate the head of cot to 30° where possible.
• Allow passive cooling via minimal blankets and using room temperature saline when fluid bolus is required.  Do not allow passive cooling in cases of traumatic cardiac arrest.
• Manage dysrhythmias in accordance with the appropriate CPG.
• Consult the Post Arrest Checklist for additional guidance.
• Consider the etiology of the cardiac arrest and treat according to appropriate CPG.

• Manage the airway in a staged approach based upon license level.
  • If the patient is able to maintain adequate oxygenation and is ventilating effectively, provide supplemental oxygen only.  Titrate oxygen flow rates to the minimum required to maintain SpO₂ ≥94%.  If pulse oximetry is unreliable because of peripheral perfusion deficits, use the highest available oxygen concentration.
  • Patients who remain comatose following a return of spontaneous circulation may have an advanced airway (either a supraglottic device or an endotracheal tube) placed.  Maintain EtCO₂ between 30 and 40 mmHg.  Monitor the patient for changes in level of consciousness, and consider the need for sedation or removal of the airway device should a gag reflex return.
• Hypotension may be managed with normal saline boluses up to 20 mL/kg as required.  Large volumes of saline are associated with poor outcomes; paramedics should aim to maintain a systolic blood pressure of 100 mmHg (or a mean arterial pressure of 65 mmHg). 
• EPINEPHrine is the preferred vasopressor in post-arrest care.
• The initial post-arrest phase can have bizarre and atypical cardiac rhythms.  Treat sustained dysrhythmias in accordance with the appropriate guidelines.  Allow at least 10 minutes following the return of spontaneous circulation for the rhythm to stabilize prior to acquiring a 12-lead ECG.
• Except in cases of traumatic cardiac arrest, allow for passive cooling.
• Elevating the head of bed to 30° promotes cerebral drainage and reduces the incidence of cerebral edema and aspiration.
• Check blood sugar and treat hypoglycemia accordingly.

Patients who have been resuscitated from cardiac arrest and who have an identified STEMI on 12-lead ECG, or who have a suspected cardiac cause of their arrest, should be transported to the closest PCI center.  If there is no PCI center within a reasonable transport time, the closest hospital must be selected.

Post arrest patients with suspected non-cardiac causes should be transported to the closest hospital.

• In patients who achieve ROSC after out of hospital cardiac arrest, subsequent morbidity and mortality are due largely to the cerebral and cardiac dysfunction that accompanies prolonged systemic ischemia.  This syndrome, called the post cardiac arrest syndrome, comprises anoxic brain injury, post cardiac arrest myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathology.
• In hospital treatment for post cardiac arrest syndrome will vary depending on the length of the cardiac arrest, the cause of the arrest, and the pre-existing co-morbidities of the patient.
• In a series in which consecutive post–cardiac arrest patients with a suspected cardiovascular cause were taken to coronary angiography, a coronary artery lesion amenable to emergency treatment was found in 96% of patients with ST elevation and in 58% of patients without ST elevation.
• Although targeted temperature management has been shown to be beneficial in post-arrest care in hospital, there is no evidence to suggest that active prehospital cooling has a positive effect on either survival or neurological recovery.  Evidence has demonstrated that large infusions of cool normal saline can adversely affect outcomes.
• Hypothermia below 35°C has a negative effect on the clotting cascade and therefore should be avoided in ROSC following a traumatic cardiac arrest.
• The clamshell can be an excellent tool in extricating the non-traumatic post arrest patient.  Once the patient has been extricated to the stretcher, the clamshell should be removed to allow 30° head up positioning.

Post-Cardiac Arrest Care