The Post-ROSC Checklist

2017-04-05T14:10:47+00:00

In emergency medicine, we are so heavily trained in resuscitation that any senior resident could recite the ACLS algorithm to you after being woken up at 3 am. However, the real work begins after the pulse return. Up to two-thirds of patients with return of spontaneous circulation (ROSC) will not survive to discharge.1,2 This approach, modeled after the 2015 American Heart Association Guidelines3 and an excellent review article by Dr. Jacob Jentzer et al,4 can help guide you through the chaos to stabilize your next post-ROSC patient.

AIRWAY

If you have not already during active resuscitation period, now is the time to intubate the patient. Make sure the hemodynamics are stable first. If you can adequately ventilate the patient there is no rush to intubate until you are completely prepared. While you are at the head, place an orogastric (OG) or nasogastric (NG) tube to decompress the stomach, which will potentially improve ventilation and reduce aspiration risk.

BREATHING

Once the patient is intubated, set your ventilator to standard lung-protective settings (tidal volume 6-8 mL/kg). Although maximum oxygenation should be used during the arrest, the goal post-arrest is just to keep the SpO2 over 94%. Do this by adjusting the PEEP and FiO2. Avoid over-oxygenation. Bedside ultrasound can confirm endotracheal tube placement, but a chest x-ray should be performed as well. End-tidal CO2 monitoring should target normocarbia (ETCO2 30-40 mmHg or PaCO2 35-45 mmHg) unless there is a specific reason to do otherwise.

CIRCULATION

Electrocardiogram

A 12-lead ECG should be done as soon as possible after ROSC. Up to 30% of ROSC patients will have a ST-elevation myocardial infarction (STEMI) and they should go immediately to the cardiac catheterization lab.5,6 Since prognostication of post-ROSC patients is very difficult early on, this recommendation applies to comatose patients as well. Even patients without ST elevation on their ECG may benefit from angiography as up to 25% have an acute occlusion.7 Finally, an initial non-shockable rhythm is not an exclusion for emergent percutaneous coronary intervention (PCI) either as 25% of these patients also required coronary intervention after ROSC.8,9

Blood Pressure

The goal blood pressure is an SBP >90 mmHg and a MAP of >65 mmHg. Begin with standard crystalloid fluid resuscitation (30 mL/kg) while using ultrasound or a straight leg raise to determine fluid responsiveness. A central line and arterial line should be placed, and if the patient has persistent hypotension then norepinephrine should be started. Epinephrine is a reasonable second vasopressor, and dobutamine should be considered for poor contractility.

Diagnostic Tests

A bedside ultrasound should be performed to exclude some causes of the arrest, such as pericardial tamponade, tension pneumothorax, and possibly a massive pulmonary embolus. A CT chest angiogram should be considered to exclude a pulmonary embolism as this has a 3% prevalence in cardiac arrest survivors.10 Labs should be sent, including an arterial blood gas (for ventilator adjustment) and lactate (for trending). Place a Foley catheter to track urine output.

DISABILITY

Targeted Temperature Management (TTM) is currently recommended for all patients regardless of rhythm. The patient should be cooled to 32–36°C as soon as possible after ROSC using whatever technique is available in your institution, and kept cool for 24 hours.11 Control shivering as needed with sedation or paralysis and consider a non-contrast head CT to exclude intracranial hemorrhage.

Post-ROSC Checklist

System Action
Airway Intubate → Ventilation tidal volume @ 6-8 mL/kg
Place OG or NG tube
Confirm endotracheal and OG/NG tube placement with chest x-ray
Breathing SpO2 goal >94% → adjust PEEP & FiO2 to achieve goal
EtCO2 goal 30-40 mmHg → adjust respiratory rate to achieve
Circulation 12-lead ECG → Activate cardiac catheterization lab for STEMI; consult cardiology for all other patients
SBP goal >90 mmHg (MAP > 65 mmHg) → Use fluids, norepinephrine infusion, then epinephrine infusion to achieve goal
Place central line
Place arterial line
Perform point of care ultrasound with the cardiac, lung, and IVC views
Send labs, which includes an arterial blood gas and serum lactate
Place Foley catheter → Goal urine output 0.5-1 mL/kg/hr
Consider CT chest angiography to rule-out a pulmonary embolism
Disability Begin cooling → Goal temperature 32–36°C
Consider head CT

 

For more information, Dr. Sean Kivlehan will be giving this talk at the 2017 UCSF High Risk Emergency Medicine Hawaii conference.

1.
McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac arrest surveillance — Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010. MMWR Surveill Summ. 2011;60(8):1-19. [PubMed]
2.
Girotra S, Nallamothu B, Spertus J, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367(20):1912-1920. [PubMed]
3.
Callaway C, Donnino M, Fink E, et al. Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S465-82. [PubMed]
4.
Jentzer J, Clements C, Wright R, White R, Jaffe A. Improving Survival From Cardiac Arrest: A Review of Contemporary Practice and Challenges. Ann Emerg Med. 2016;68(6):678-689. [PubMed]
5.
American C, Society for, O’Gara P, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):485-510. [PubMed]
6.
Peberdy M, Donnino M, Callaway C, et al. Impact of percutaneous coronary intervention performance reporting on cardiac resuscitation centers: a scientific statement from the American Heart Association. Circulation. 2013;128(7):762-773. [PubMed]
7.
Rab T, Kern K, Tamis-Holland J, et al. Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient. J Am Coll Cardiol. 2015;66(1):62-73. [PubMed]
8.
Stær-Jensen H, Nakstad E, Fossum E, et al. Post-Resuscitation ECG for Selection of Patients for Immediate Coronary Angiography in Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Interv. 2015;8(10). [PubMed]
9.
Wilson M, Grossestreuer A, Gaieski D, Abella B, Frohna W, Goyal M. Incidence of coronary intervention in cardiac arrest survivors with non-shockable initial rhythms and no evidence of ST-elevation MI (STEMI). Resuscitation. 2017;113:83-86. [PubMed]
10.
Bougouin W, Marijon E, Planquette B, et al. Factors Associated With Pulmonary Embolism-Related Sudden Cardiac Arrest. Circulation. 2016;134(25):2125-2127. [PubMed]
11.
Donnino M, Andersen L, Berg K, et al. Temperature Management After Cardiac Arrest: An Advisory Statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Resuscitation. 2016;98:97-104. [PubMed]

Sean Kivlehan, MD MPH

Sean Kivlehan, MD MPH

Associate Director
International Emergency Medicine Fellowship
Department of Emergency Medicine
Brigham and Women's Hospital
Harvard Medical School
Sean Kivlehan, MD MPH

Latest posts by Sean Kivlehan, MD MPH (see all)

  • Julian Villar

    I love this, nicely done Dr Kivlehan.
    My only suggestion would be to put Circulation first, and within circulation, getting a BP as the first action item.
    My other comment would be to think of epinephrine primarily as an inotrope and to use it as your inotrope of choice post ROSC; avoid dobutamine early in the course unless the patient is super hypertensive.

    Well played, sir

    • Sean Kivlehan

      Thanks for the comment Dr. Villar. That’s a really good point. I was tinkering with the ABCD to make it easy, but CAB probably makes sense after ROSC just like in regular cardiac arrest. Stabilize the BP, and get the ECG. As for Epi vs Dobutamine, also a really good point. The associated vasodilation could definitely be an issue for an unstable patient – and the epi is familiar and readily available.

  • Jim Mobley

    This is a great article that talks about the “after” rather than the “during” of resuscitation. While post code, we are elated that we have ROSC, systematic and prioritized patient care is paramount. Often pushed to the low priority column, temp management has to be a high priority in all ROSC situations. Cooling is a game changer when it comes to salvaging neuro function in post ROSC patients.

    • Sean Kivlehan

      Thanks for the comment Jim. You are absolutely right – in the past the emphasis was on managing the arrest, but I think we need to remember to focus on the post-arrest as these are the patients we can help the most.

  • Nick Johnson

    This is a really nice, concise review of key steps that should be taken immediately post-ROSC. Well-done! A couple of comments: use end-tidal CO2 as a surrogate for PaCO2 cautiously in this population. A low end-tidal CO2 may reflect inadequate cardiac output and/or high dead space, both of which are common after cardiac arrest, rather than arterial hypocarbia. Our group (sorry, shameless plug) recently demonstrated that initial normocarbia is associated with favorable neurologic outcome after OHCA (PMID: 28268187). It’s important to get it right; for this reason, I highly encourage early blood gas analysis in this population. I also really like that you encourage the use of low-tidal volume ventilation. A recently published study also demonstrated improved neurologic outcome in patients treated with tidal volumes <8 ml/kg (PMID: 28267376). There's more to the tidal volume story to come, but I think it's good practice to keep them low after ROSC.

    • Sean Kivlehan

      Thanks so much for the comment Nick, and I am really glad you enjoyed it. The point you make about the ETCO2 is correct on both fronts: you need a blood gas analysis as early as possible, and there increasing evidence of correlation between CO2 levels and outcomes. Thanks for bringing this up – it is one of the many important points that are covered in this checklist and reflects the rapidly growing evidence in this field.

  • Mathieu Moreau

    Great post!
    I use the acronym CAB-TTM
    Temperature
    Transfer
    Monitoring
    Grouping all the monitoring together, it can more easily be delegated to nurses. We explicitely remind the team to draw a blood glucose.
    It also emphasizes two important aspects of the post-ROSC patient: the TTM (we use 36 in the ER at both of my institutions) and the decision branch point of whether to transfer or not.

    • Sean Kivlehan

      Hi Mattieu – So glad you enjoyed the post! I love that acronym, CAB-TTM, may use it myself.