ACLS Advanced cardiac life support (Latest 2020 AHA)

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Post ROSC management detailed – 2020 guidance

As we continue the CPR, at every 2 min interval we tend to check if there is a pulse. Once there is a palpable pulse, we call it return of spontaneous circulation – ROSC in short. The care given after pulse is achieved is called as “Post ROSC management”.


If the post ROSC management is not done systematically and carefully, we might lose the pulse (re-arrest) which will need CPR again. We are supposed to check for the cause of cardiac arrest and make sure to resolve it to prevent another arrest. The same reversible causes 5Hs and 5Ts must be checked for again and again.

ABCD manner


As discussed, we must avoid Hypoxia as it’s one of the reversible cause. Make sure the airway is patent and establish an advanced airway if not already secured during the CPR. Intubation – endotracheal tube placement must be confirmed with waveform capnography.


Check if the patient is breathing after ROSC. If the breathing effort is inadequate or absent, we need to support the breathing with a ventilator (Artificial breaths).
Aim for :

  • Start at 10 breaths/min and titrate
  • Maintain an Oxygen saturation – spO2 of 92-98%
  • Arterial CO2 – PaCO2 of 35-45 mmHg


Check the blood pressure (Via cuff manometer or invasive arterial line) and if the blood pressure is low, we can try fluid bolus via Intravenous Crystalloids (Normal saline or Ringer lactate etc.). If the fluids alone are not helping, we may have to start vasopressors which constrict the blood vessels or inotropes which improve heart contractility to increase the blood pressure.
Aim for

  • Systolic blood pressure of 90 mmHg plus
  • Or Mean arterial blood pressure MAP of 65 mmHg plus

Think of getting a 12 lead ECG and draw blood samples for routine investigations (ABG, electrolytes etc.).

Urgent cardiac intervention is needed if there is (Call the specialist)

  • ST elevation myocardial infarction (STEMI) on ECG
  • Unstable cardiogenic shock (Shock / persistent hypotension due to poor heart function)
  • Mechanical cardiac support (like IABP – intra arterial balloon pump) is required.


Check the responsiveness of the patient and if the patient is following commands, shift to critical care unit. If not following commands, initiate the following before shifting to the critical care.

  • Targeted temperature management (32-36 °C for at least 24hrs)
  • Ct scan of Brain
  • Electro encephalogram EEG
  • Continuous core temperature measurement (with Esophageal / rectal / bladder probes)
  • Maintain normal Oxygen / Carbon di oxide / Glucose levels

Post ROSC management is not complete without considering reversible causes.