Post-Cardiac Arrest Care and Temperature Control

Post-cardiac arrest care begins at return of spontaneous circulation (ROSC). It is a set of physiologic goals and time-sensitive decisions, and ROSC does not end the work. Four aims: restore perfusion, prevent secondary brain and myocardial injury, find the cause of the arrest, and hold any neurologic prognosis until confounders clear. The 2025 AHA and ERC-ESICM guidelines both cover these topics.

• Mechanism: ischemia during the arrest, then reperfusion. Together they drive myocardial stunning, systemic inflammation, hypotension and hypoxic-ischemic brain injury.
• Common causes: acute coronary occlusion is a frequent cause, especially after a shockable rhythm. The rest are the reversible causes of arrest (see Adult Cardiac Arrest).
• Course: early deaths after ROSC usually come from refractory shock or brain injury. Most of the risk sits in the first hours after ROSC.

Presentation After ROSC

• Circulation: a palpable pulse with a perfusing rhythm and a sustained EtCO₂ rise during CPR.
• Consciousness: plenty of patients stay unresponsive after ROSC. A comatose patient needs the temperature, oxygen and prognosis pathway. A pulse check does not cover that.

Red Flags

• Adult MAP below 65 mmHg, or poor perfusion despite a pulse (pediatric BP goals are age-based; see Special Populations)
• SpO₂ outside 90–98%, or hyperoxia on high FiO₂
• Core temperature above 37.5 °C (99.5 °F)
• Seizure or myoclonic activity
• ST elevation on the post-ROSC 12-lead ECG

Run the assessment alongside the first post-ROSC interventions. Don't hold the blood pressure or oxygen targets while you finish the work-up.

• Coma from drugs or sedation: sedatives, opioids and neuromuscular blockers given during resuscitation can delay waking. A flat exam is not a final neurologic state.
• Coma from metabolic causes: hypoglycemia and hypothermia can cause coma. It clears once you correct them. Check glucose and temperature first.
• Non-cardiac cause of arrest: hypoxia, hemorrhage, toxins or pulmonary embolism may explain the arrest. That may change the post-ROSC plan.

1. Confirm ROSC: check for a pulse and for breathing that is no longer agonal. Continue monitoring for re-arrest.
2. Protect the airway: position the patient, suction as needed and give oxygen while the airway is managed.
3. Ventilate steadily: with a bag-valve mask or device, avoid hyperventilation and excess ventilation.
4. Keep the patient monitored: watch for re-arrest, vomiting and seizures. Keep the patient warm if cold, and avoid active warming beyond local protocol.
5. Notify and transport: report the arrest time, ROSC time, shocks and drugs given, and send the patient to the destination the protocol names.

Your local protocols and medical direction settle the airway devices, oxygen targets and destination.

The doses live on the linked medication pages. Where this page gives no dose, follow local protocols and medical direction.

• Monitoring and 12-lead (Paramedic/RN/CCT): keep continuous ECG, SpO₂, waveform EtCO₂ and blood pressure running. Get a 12-lead ECG as soon as feasible after ROSC (2025 AHA Part 11, COR 1).
• Oxygen (Paramedic/RN/CCT): give 100% oxygen until SpO₂ or PaO₂ can be measured reliably (2025 AHA Part 11, COR 1). Then titrate FiO₂ to an SpO₂ of 90–98% (PaO₂ 60–105 mm Hg). Avoid both hypoxemia and hyperoxemia (COR 2a). Pulse oximetry can hide hypoxemia in darker skin (COR 2b). Wean as soon as it is safe. See Capnography.
• Blood pressure (Paramedic/RN/CCT): aim for an adult MAP of at least 65 mmHg (2025 AHA Part 11, COR 1). Give fluid per protocol if the patient is hypovolemic. If MAP stays below goal, start a vasopressor infusion. AHA 2025 finds insufficient evidence to recommend one specific vasopressor after arrest (COR 2b). Norepinephrine is a high-alert infusion. Run it on a pump through a secure large-bore IV or central access, watch the site for extravasation, and never give it as an IV push. See Norepinephrine.
• Ventilation and airway (Paramedic/RN/CCT): place an advanced airway if it is needed, and confirm it with waveform capnography. Titrate ventilation to a PaCO₂ of 35–45 mm Hg in comatose adults. Avoid hyperventilation (2025 AHA Part 11, COR 1). See Intubation.
• Temperature (Paramedic/RN/CCT): start fever prevention and cooling at once. For adults who stay unresponsive to verbal commands, hold 32–37.5 °C (89.6–99.5 °F) (2025 AHA Part 11, COR 1) for at least 36 hours (COR 2a). Fever prevention stays at or below 37.5 °C.
• Glucose (Paramedic/RN/CCT): check it, and treat any value below 70 mg/dL. AHA 2025 suggests avoiding glucose below 70 mg/dL and above 180 mg/dL (COR 2b). See Dextrose.
• Seizures (Paramedic/RN/CCT): treat clinical seizures per protocol and reassess for ongoing seizure activity.

• Coronary evaluation: go straight to emergent coronary angiography and percutaneous coronary intervention for persistent ST elevation, coma or not (2025 AHA Part 11, COR 1). Angiography before hospital discharge is recommended for survivors with a suspected cardiac cause (COR 1). In comatose patients without ST elevation, emergency angiography is not recommended over a delayed or selective strategy unless there is shock, electrical instability or ongoing ischemia (COR 3: No Benefit). Selected patients with shock, recurrent ventricular arrhythmia or ongoing ischemia may be angiographed (COR 2a).
• Hemodynamics: keep adult MAP at least 65 mmHg, with vasopressor support. The E3 reference dose is norepinephrine, 0.05–0.5 mcg/kg/min IV infusion titrated to MAP (see Norepinephrine).
• Temperature control: hold 32–37.5 °C and prevent fever for at least 36 hours in adults who stay unresponsive to verbal commands (2025 AHA Part 11, COR 2a). Don't stop control early just because cooling has ended. 36 hours is the shortest duration the guideline recommends.
• Neuroprognostication: don't make the call early. Firm up the prognostic impression at a minimum of 72 hours after normothermia and after sedatives are stopped (2025 AHA Part 11, COR 2a). Wait until sedation, neuromuscular blockade and hypothermia effects have cleared. AHA 2025 gives separate prognostic statements for favorable and unfavorable outcome. It calls for several modalities together: neurologic exam, EEG, somatosensory evoked potentials, neuroimaging and serum biomarkers, interpreted by the team.
• Seizures and myoclonus: watch for seizures with EEG when you have it, and treat per protocol.
• Cause: finish the work-up for what caused the arrest. ECPR is an option only where the system and team support it (see ECMO).

• Destination: when local protocol allows, skip the nearest facility and take ROSC patients to a PCI-capable center with post-arrest care.
• In transit: keep ECG, SpO₂, EtCO₂ and blood pressure on continuously. Check glucose and temperature at intervals per protocol.
• Infusions: run vasopressor infusions on a pump with a dedicated line. Confirm the concentration and the weight-based rate. Norepinephrine is a high-alert infusion. Keep a secure large-bore IV or central line, check the site for extravasation at intervals, and follow the Norepinephrine page for concentration and rescue.
• Handoff: time of arrest and ROSC, shocks, drugs and doses, rhythm history, glucose, temperature and whether the patient was comatose after ROSC.

• Pediatrics: targets and drug doses change with age. Blood pressure: keep systolic and mean pressure above the 10th percentile for age, not the adult MAP of 65 mmHg (2025 AHA Part 8, COR 1); see Pediatric Vital Signs and the Norepinephrine page. Temperature: monitor central temperature continuously and avoid central temperatures above 37.5 °C (COR 1); a 5-day course of 32–34 °C followed by 36–37.5 °C, or 36–37.5 °C alone, is reasonable for children who remain comatose (COR 2a). Oxygen: wean to SpO₂ 94–99% (COR 2b) and target a PaCO₂ of 35–45 mm Hg, or the baseline value in chronic hypercapnia (COR 2b). Glucose: the 2025 AHA PALS text gives no pediatric glucose target. Use the pediatric protocol. Seizures: treat clinical seizures (COR 1) and use continuous EEG when resources allow (COR 1). Vasopressor dosing for children: 0.05–0.5 mcg/kg/min IV/IO infusion titrated to age-based BP and perfusion (NASEMSO Shock p.109; see Norepinephrine). Differs: PICU practice titrates above 0.5 mcg/kg/min (to 2); specialist use; not FDA-established. See Pediatric Cardiac Arrest, Pediatric Vital Signs and weight-based dosing.
• Pregnancy: from about 20 weeks, use left uterine displacement during resuscitation and bring obstetric care in early. Maternal resuscitation and perimortem decisions run per obstetric and local protocol.
• Older Adults: no specific adjustment is established. Individualize blood pressure goals per protocol.
• Renal Impairment: no specific adjustment is established. Review drug dosing per local protocol.

• Error: stopping temperature control or fever prevention while the patient is still comatose. Keep going for at least 36 hours (2025 AHA Part 11, COR 2a), or longer if your protocol requires.
• Error: calling ROSC the end of the emergency. Hypotension, hypoxia and re-arrest all come back. Reassess continuously.
• Error: leaving FiO₂ high after ROSC. Once SpO₂ allows, titrate oxygen down into the target range.
• Error: missing a STEMI on the post-ROSC ECG. If the first 12-lead is unclear, repeat it.
• Error: calling neurologic prognosis early, while sedation, paralysis or hypothermia still skew the exam.
• Error: starting a vasopressor without a confirmed concentration and rate. Confirm the mcg/kg/min order before the pump starts.