Return of Spontaneous Circulation

• Early recurrence of VF is common; ensure appropriate ongoing monitoring through defibrillator pads.

• Undertake a structured <C>ABCDE assessment that enables appropriate treatment to be applied, as described in the immediate management below. Consider and continue to treat any reversible cause of the initial cardiac arrest.

• Measure and record a full set of observations and repeat these at regular intervals.

• Early optimisation of airway, breathing and circulatory support will assist in the heart and brain recovery.

• Forward planning ‒ ensure appropriate resources are on scene or requested to the scene; this may include enhanced care.

• Consider the extrication plan and facilitate preparations for extrication and onward transfer.

• Transfer the patient directly to the nearest appropriate hospital in accordance with local pathways for primary percutaneous coronary intervention (PPCI) or ECMO (where available).

• Provide an ATMIST pre-alert call to the receiving facility.

Airway and Breathing

• Ensure an effective airway; consider enhanced care support for advanced airway insertion or maintenance.

• Maintain oxygen saturations of 94–98%; titrate oxygen to prevent hypoxia or hyperoxia. Refer to Oxygen.

• Assist ventilations where required.

• Use of a mechanical ventilator (if available) is preferable to manual ventilation; ensure the settings are appropriate for age, weight and rate (generally a tidal volume of 6‒7 ml/kg with a rate of 10/min).

• Monitor waveform capnography.

• Ventilate lungs to normocarbia (4.6‒6.0 kPa); consider the reason for readings that fall outside normocarbia, i.e. is this a perfusion, ventilation or metabolic issue?

Circulation

• Perform a 12-lead ECG.

  • NB Post-ROSC ECGs frequently demonstrate a ‘recovering heart’; therefore, ECGs should be obtained at regular intervals.

• Ensure adequate vascular access.

• Following ROSC, patients are often haemodynamically unstable, arrhythmogenic and hypotensive. Aim for a systolic blood pressure (SBP) >100 mmHg. In patients with an adequate heart rate, attempt to achieve this with IV (or IO) fluids, together with IV (or IO) adrenaline (see below for the management of bradycardia).

• Most patients who suffer a cardiac arrest due to a cardiac cause are not hypovolaemic, but vasodilation may result in the circulation being relatively underfilled. Administer a  250 ml IV/IO bolus of 0.9% saline, repeated as necessary to a maximum of 500 ml. Patients with sepsis, anaphylaxis, respiratory conditions and dehydration may benefit from larger volumes; seek medical advice in these cases.

• In the event of symptomatic bradycardia in adults (HR <60/min), atropine should be administered.

• In the event of symptomatic bradycardia in children/infants, first ensure that hypoxia has been reversed (the commonest cause of bradycardia).

• If bradycardia persists, external pacing should be considered.

• NB APP | CCP: Although 250–500 ml of IV (or IO) fluid may support the circulation, it may take several minutes to administer. If hypotension is present during or after this fluid administration, provide additional circulatory support using careful administration of an adrenaline bolus, repeated as required, every 3–5 mins to maintain the systolic BP >100 mmHg. 

  • Initial dose:  50 mcg (0.05 mg) IV/IO. (0.5 ml from a 1:10,000 pre-filled 10 ml adrenaline syringe).

  • Subsequent doses: 50–100 mcg (0.05–0.10 mg). (0.5–1.0 ml from a 1:10,000 pre-filled 10 ml adrenaline syringe).

  • Follow each adrenaline bolus with a flush of 20 ml 0.9% normal saline.

Control Temperature

• There is no evidence that cooling patients post-ROSC is of benefit, but extremes of temperature are harmful. Some patients post ROSC will have a mild hypothermia. Use no more clothing/blankets than is necessary. Vehicle heating is only required to provide a comfortable ambient temperature.

• Aim for a core temperature no higher than 37.5°C.

Blood Glucose Level

• Measure and record blood glucose for hypo/hyperglycaemia (refer to Glycaemic Emergencies in Adults and Children).

• Accuracy of blood glucose measurements immediately following ROSC may be impaired by capillary blood stasis. Venous blood glucose is preferred to capillary samples and should be measured and repeated 10 minutes following ROSC.

Combative Patient

• Following ROSC, patients may be cerebrally irritated, agitated or combative, which can make oxygenation difficult.

• Exclude hypoglycaemia and hypoxaemia.

• Try to establish why the patient may be agitated, such as in pain, need for oxygenation or airway device removal.

• If available, request additional support from enhanced care teams to consider the need for anaesthetic management or sedation, as per local procedures.

• This should only be provided by defined teams or individuals in line with robust governance and scope of practice.

Pain Relief

• CPR is a painful procedure, therefore the patient is likely to be in pain.

• Consider the provision of analgesia (IV paracetamol, supplemented with a small dose of opiates) following resuscitation efforts.

• Observe and manage respiratory function after opiate administration.

Seizure Control

• Seizures that do not self-terminate within 5 minutes may be treated with a benzodiazepine

• The administration of diazepam or midazolam (where available) should be carried out in line with clinical practice guidelines or PGD (in the context of midazolam).