Cardiac arrest: adult ACLS
Post-cardiac arrest care after ROSC
Sets the post-resuscitation bundle after return of spontaneous circulation. Decides on immediate coronary angiography (ST elevation, shock or electrical instability) versus a delayed strategy, and sets oxygenation, ventilation and haemodynamic targets, the target temperature in comatose survivors and how to reach and hold it (core probe, feedback device, shivering control, rewarming), seizure and glucose management, the timing of neurological prognostication, and the multidisciplinary post-cardiac arrest care team. ERC-ESICM and ESC recommendations are shown beside the AHA 2025 guideline.
Upload a report, lab sheet or echo picture to fill this calculator automatically.
After ROSC
12-lead ECG within 10 minutes of ROSC
Targets
Post-cardiac arrest care
ROSC
Stabilise and find the cause
Post-resuscitation bundle
ESC
- No ST elevation and stable: no routine immediate angiographyIIIESC ACS 2023COACT and TOMAHAWK showed no benefit from immediate angiography; assess for a delayed invasive strategy.
- Airway and breathingIERC-ESICM 2025Waveform capnography; SpO₂ 94–98% (avoid hypoxia and hyperoxia); normocapnia, PaCO₂ 35–45 mmHg (4.5–6.0 kPa); lung-protective ventilation.
- CirculationIERC-ESICM 2025MAP > 65 mmHg with fluids, noradrenaline and dobutamine as needed; echo; urine output > 0.5 mL/kg/h; lactate falling. Consider mechanical circulatory support in refractory cardiogenic shock.
- Find the causeIERC-ESICM 202512-lead ECG, echo, blood gas, electrolytes and troponin; CT head and CT pulmonary angiography when there is no obvious cardiac cause. ICD assessment later for VF without a reversible cause.
AHA 2025
- Emergency angiography not recommended in stable comatose patients without STEMI3AHA 2025Decide after neurological and clinical reassessment.
- Oxygenation and ventilation2bAHA 2025SpO₂ 92–98%; PaCO₂ 35–45 mmHg.
- Haemodynamic targets2aAHA 2025Avoid SBP < 90 and MAP < 65 mmHg.
Target temperature
ESC
- Following commands: no temperature-control protocolERC-ESICM 2025Monitor temperature and treat fever; look for its cause (aspiration pneumonia is common).
- No prehospital cooling with rapid infusion of cold IV fluidsIIIERC-ESICM 2025More re-arrest and pulmonary oedema without better outcome (Kim 2014).
AHA 2025
- Temperature control is for patients not following commandsAHA 2025Treat fever and search for infection.
- No routine prehospital cooling with rapid cold IV fluids3AHA 2025
How to reach and hold the target
- 1. Measure core temperature continuouslyERC-ESICM 2025Bladder, oesophageal or intravascular probe (or rectal). Not tympanic, axillary or skin.
- 2. Use a feedback-controlled deviceERC-ESICM 2025Surface gel pads or an endovascular catheter that adjusts to the core probe. Ice packs, cold fluids and fans alone overshoot and drift; use them only as a bridge.
- 3. Sedate, give analgesia and control shiveringAHA 2024Shivering raises temperature and oxygen use. Score it (Bedside Shivering Assessment Scale) and step up: paracetamol, skin counter-warming, magnesium (keep Mg²⁺ ≥ 1 mmol/L), buspirone, then dexmedetomidine, propofol or opioid, and neuromuscular blockade if refractory (with continuous EEG).
- 4. Expect the physiology of coolingAHA 2024Bradycardia (normal if perfusing), cold diuresis, hypokalaemia, hypomagnesaemia and hypophosphataemia while cooling, rising potassium on rewarming; hyperglycaemia; slower drug clearance. Check gases, electrolytes and glucose every 4–6 h.
- 5. Rewarm slowlyAHA 2024After a 32–36 °C target: 0.25–0.5 °C per hour to normothermia, with the device still in control to avoid rebound fever.
- 6. Keep preventing fever to 72 hERC-ESICM 2025Leave the device on in comatose patients; prognosticate off sedation, no earlier than 72 h after ROSC.
Post-cardiac arrest care team
Treat out-of-hospital cardiac arrest survivors in a cardiac arrest centre: 24/7 cath lab, ICU with temperature control, mechanical circulatory support, neuroprognostication and rehabilitation, with one multidisciplinary team owning the patient from arrival to follow-up (ERC-ESICM 2025; AHA 2025).
- Team leader: emergency physician or intensivistRuns the post-ROSC bundle, sets the targets and the plan, and talks to the family
- Interventional cardiologist12-lead ECG review, echo, decision and timing of coronary angiography and PCI (24/7 cath lab)
- Critical care nursesTemperature device, shivering score, sedation, ventilation, haemodynamic and glucose targets
- Heart team / mechanical circulatory supportCardiac surgeon, perfusionist and shock team for refractory cardiogenic shock, ECMO or Impella
- Neurologist and neurophysiologyEEG for seizures, multimodal prognostication (exam, SSEP, NSE, CT/MRI) from 72 h
- RadiologyCT head and CT pulmonary angiography when the cause is not cardiac
- ElectrophysiologistArrhythmia cause, ICD decision before discharge, genetic and family screening after unexplained arrest
- Rehabilitation teamPhysiotherapy, occupational therapy, neuropsychology: functional assessment before discharge, follow-up within 3 months (cognition, mood, fatigue)
- Palliative care, social work and chaplaincyFamily support, goals of care, organ donation pathway when brain death or withdrawal of treatment
ESC column shows ERC-ESICM post-resuscitation care and the ESC 2023 ACS guideline for angiography.
References
- American Heart Association. 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 9: Adult advanced life support. Circulation 2025;152(suppl 2).
- European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2025: Post-resuscitation care. Resuscitation 2025.
- Byrne RA, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023;44:3720-3826.
- Lemkes JS, et al. Coronary angiography after cardiac arrest without ST-segment elevation (COACT). N Engl J Med 2019;380:1397-1407.
- Desch S, et al. Angiography after out-of-hospital cardiac arrest without ST-segment elevation (TOMAHAWK). N Engl J Med 2021;385:2544-2553.
- Dankiewicz J, et al. Hypothermia versus normothermia after out-of-hospital cardiac arrest (TTM2). N Engl J Med 2021;384:2283-2294.
- Nielsen N, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest (TTM). N Engl J Med 2013;369:2197-2206.
- Kim F, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest. JAMA 2014;311:45-52.
- Hirsch KG, et al. Critical care management of patients after cardiac arrest: a scientific statement from the American Heart Association and Neurocritical Care Society. Circulation 2024;149:e168-e200.
- Sinning C, et al. The cardiac arrest centre for the treatment of sudden cardiac arrest due to presumed cardiac cause: aims, function, and structure. Position paper of the ACVC association of the ESC, EAPCI, EHRA, ERC, EUSEM and ESICM. Eur Heart J Acute Cardiovasc Care 2020;9(4 suppl):S193-S202.
More in Cardiac arrest: adult ACLS