🫀 Post-ROSC Care

JRCALC G0125 · v9.36 · 15 Apr 2026 · NWAS
ROSC ACHIEVED
⚠ RE-ARREST RISK — MAINTAIN MONITORING — RAPID TRANSFER
Post-ROSC Assessment
Cardiac arrest care has achieved ROSC. Begin structured assessment.
⚠ Early Re-arrest Risk Early recurrence of VF is common. Ensure defibrillator pads remain in place and monitor continuously.

Arrest Context

Airway & Breathing
Immediate post-ROSC management
Oxygen Target Use 100% O₂ immediately post-ROSC until SpO₂ reliable. Then titrate to 94–98% SpO₂. Avoid hypoxia AND hyperoxia.
⚠ Dark Skin Tones Pulse oximetry may overestimate true SpO₂. Low-flow states reduce signal quality. Interpret with caution.

Observations

EtCO₂ / Ventilation

EtCO₂ Target: 4.0–5.5 kPa Use as surrogate for PaCO₂. EtCO₂ may underestimate arterial CO₂ post-arrest. Aim ~10 breaths/min with advanced airway.
⚠ Tension Pneumothorax High index of suspicion at any point post-ROSC. If suspected — decompress immediately with needle thoracocentesis.
Airway Checklist
⬜Effective airway confirmed / maintained
⬜Oxygen applied — titrating to SpO₂ 94–98%
⬜Waveform capnography attached and monitored
⬜Ventilation rate ~10/min — EtCO₂ trending in target range
⬜Tension pneumothorax considered / excluded

Circulation
Haemodynamic assessment & management

Blood Pressure

BP Targets Medical arrest: SBP >100 mmHg  |  Traumatic arrest: SBP >80 mmHg
If raised ICP suspected in trauma: consider target SBP >100 mmHg

12-Lead ECG

Post-ROSC ECGs frequently show ST-elevation and ischaemic changes from a 'recovering heart'. Obtain at regular intervals.

⬜12-lead ECG performed and interpreted
⬜IV / IO access confirmed
⬜Defibrillator pads remain in place — continuous monitoring

Fluid Management
Post-ROSC circulatory support

Sodium Chloride 0.9% — Fluid Bolus

Medical arrest: Initial 250mL bolus IV/IO Repeat as necessary. Maximum 500mL for cardiac aetiology.
Sepsis / anaphylaxis / dehydration may require larger volumes — seek clinical advice.
1
Fluid Bolus
NaCl 0.9% — 250mL IV/IO
Initial bolus. Reassess BP after.
⬜
2
Repeat if required
NaCl 0.9% — 250mL IV/IO
Max total 500mL (cardiac aetiology)
⬜

Adrenaline 1:10,000 — Post-ROSC Inotropic Support

NWAS NW0140 v15.27 — Approved 05 Feb 2025 All NWAS Paramedics authorised following completion of training and competency assessment. ≥12 years and adult only.

▶ Indications — ALL THREE must be present

⬜Systolic BP <100 mmHg
⬜HR <100 bpm
⬜Radial pulse ABSENT
Note — Radial pulse present & SBP <100 Consider 250mL NaCl 0.9% IV/IO first. Radial pulse must be absent before giving adrenaline.

✕ Contraindications — do not give if any present

ABSOLUTE CONTRAINDICATIONS Core temperature <30°C  |  SBP >100 mmHg  |  HR >100 bpm  |  Radial pulse present

⚠ Cautions

Temperature 30–35°C Double the interval between doses (i.e. every 6–10 minutes instead of 3–5 minutes) — per Resuscitation Council guidelines.
Non-cardioselective beta-blockers (e.g. propranolol) Risk of severe hypertension.
Extravasation risk Administer into a large vein or IO. If extravasation occurs: stop, gain new access, remove affected line, inform hospital, complete incident form.

⚗ Preparation — 3-Way Tap Method

1. Use adrenaline pre-filled syringe 1mg in 10mL (1:10,000)
2. Attach a 3-way tap to the pre-filled syringe
3. Attach an empty 1mL or 2mL syringe to another port of the 3-way tap
4. Close the 3rd port on the 3-way tap
⚠ Do NOT attach the 3-way tap to the patient — used for decanting only
5. Decant 50 micrograms (0.5mL) into the empty syringe, then remove from tap before administering

💉 Dosing

1
Initial Dose · ≥12 yrs & adult
Adrenaline 1:10,000 — 50 micrograms
0.5mL decanted via 3-way tap → administer IV/IO bolus + 20mL NaCl 0.9% flush
⬜
2+
Repeat Doses · Every 3–5 min (6–10 min if temp 30–35°C)
Adrenaline 1:10,000 — 50–100 micrograms
0.5–1.0mL IV/IO bolus + 20mL NaCl 0.9% flush. No maximum dose limit.
⬜
Stop when: SBP >100 mmHg achieved Reassess BP, HR and radial pulse before each dose. Record each dose as an event on defib equipment using the "Event" button.

📋 Pre-Dose Checklist (before each dose)

⬜BP measured and SBP <100 mmHg confirmed
⬜HR <100 bpm confirmed
⬜Radial pulse absent confirmed
⬜Core temp ≥30°C confirmed (contraindicated if <30°C)
⬜Each dose recorded as event on defib equipment

Additional Management
Temperature · BGL · Bradycardia · Agitation · Seizures

Temperature Control

Target: Core Temp ≤37.5°C No benefit to active cooling. Extremes of temperature are harmful. Mild hypothermia (32–36°C) — do NOT actively rewarm. Prevent further heat loss only.
⬜Temperature managed — appropriate clothing/blankets only

Blood Glucose

Check BGL — Accuracy may be impaired post-ROSC Capillary stasis affects accuracy immediately post-ROSC. Venous BGL preferred. Repeat 10 minutes post-ROSC.
⬜BGL repeated at 10 minutes post-ROSC

Bradycardia (HR <60/min)

Adults: Atropine — refer JRCALC Atropine Sulfate guideline Children: Reverse hypoxia first (commonest cause). If persists — consider Atropine. External pacing: not core competency — request PHEC/enhanced care or clinical advice.
⬜Bradycardia assessed — atropine / pacing considered

Combative / Agitated Patient

Post-ROSC Cerebral Irritation Agitation can compromise oxygenation. Exclude hypoglycaemia and hypoxaemia first. Consider PHEC/enhanced care for anaesthetic management or sedation.
⬜Hypoglycaemia excluded
⬜Hypoxaemia excluded / corrected
⬜PHEC / enhanced care considered for sedation

Pain Relief

⬜Conscious patient — analgesia considered and provided

Seizure Control

Seizures >5 minutes: Benzodiazepine Refer to JRCALC Seizures in Adults / Children guideline.
⬜Seizures monitored — benzodiazepine given if >5 minutes

Enhanced / Critical Care

⬜PHEC / enhanced care considered / requested
⬜Extrication plan in place — resources on scene

Disposition & Pre-Alert
Destination decision and ATMIST handover

Destination

Medical (Cardiac) Arrest Transport to nearest hospital with 24/7 coronary angiography capability. This applies to both STEMI and non-STEMI patients. Cardiac arrest centre preferred.
Traumatic Cardiac Arrest Transport in line with local major trauma pathways — normally Major Trauma Centre if trauma unit bypass criteria met.

ATMIST Pre-Alert

AAge / Sex—
TTimeTime of collapse / ROSC: —
MMechanism—
IInformation—
SSigns—
TTreatment—

Summary & PCR
Event log and documentation

Drug / Intervention Log

No events logged yet.
Documentation Checklist
⬜Full observation set documented at regular intervals
⬜All 12-lead ECGs documented / transmitted
⬜All drugs and doses documented with timestamps
⬜ATMIST pre-alert given to receiving hospital
⬜Verbal handover completed at hospital — concise and clear