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Return of Spontaneous Circulation (ROSC)

ROSC occurs when a patient, who was previously in witnessed cardiac arrest, resumes an adequately perfusing rhythm with sustained respiratory effort. ROSC has been reported as occurring in 31-65% of out of hospital cardiac arrests1


In any patient who attains ROSC the following should be considered: 2, 3


  1. Airway

    1. Raise the head of the bed to 30o (if clinically appropriate) to help maintain airway drainage.

    2. Consider airway adjuncts as required

    3. If a patient has received paralytics, ensure correct maintenance of anaesthesia +/- analgesia

    4. Utilise an oro- or naso-gastric tube to decompress the stomach if gastric distension and/or vomiting is a concern. 4

  2. Breathing

    1. Monitor SpO2 and maintain a value of 94-96%

    2. Monitor EtCO2 and maintain a value of 30-45 mm/Hg. Avoid hyperventilation/hypocarbia.

  3. Circulation

    1. Ensure a patent IV has been established

    2. Ensure appropriate cerebral perfusion (which is often reduced in ROSC), a BP of 100 -120 mm/Hg is appropriate.

      1. Metaraminol IV is appropriate to help maintain blood pressure in the normovolaemic, hypotensive patient.  If in doubt of fluid status, administer a 10-20 mL/kg bolus of normal saline prior to initiating metaraminol treatment.5

        1. Initial bolus is 0.5-1.0 mg

        2. Ongoing infusion should then be started, initially at 2mg/hr – titrating to effect (if using an infusion pump)

        3. Alternatively, repeat boluses by IV push of 0.5-1.0 mg of metaraminol every 5-10 minutes as required, titrating to effect

      2. For normovolaemic, hypotensive patients refractory to metaraminol, consider adding an IV adrenaline infusion.          

        1. 0.5 mg/hr by infusion pump, adjusting to titrate to effect.

        2. If no infusion pump is available, add 1 mg of adrenaline to 1000 mL of normal saline solution.  Start the infusion at 2 drops per second and titrate to effect.

        3. Or, administer 100 mcg of adrenaline every one to two minutes, titrating to effect.

    3. Cardiac dysrhythmias should be appropriately treated as per CPGs

    4. Maintaining an infusion of an antidysrhythmic that successfully restored a perfusing rhythm is appropriate.

    5. All ROSC patients should have a 12 lead ECG obtained as soon as possible. 

    6. Any patient showing signs of STEACS on 12 lead, or with an incident and/or medical history consistent with ACS should be transported to a receiving facility with emergency cardiac catheterisation capability.

  4. Dextrose

    1. Attempt to maintain euglycaemia.  Be judicious with raising blood sugar levels as hyperglycaemia is associated with worsened patient outcomes.  Hyperglycaemia can be lowered, but ensure that the patient is not forced into a hypoglycaemic state. 4, 6

  5. Exposure

    1. Do not actively rewarm patient.  At room temperature they should be covered with a sheet only.

  6. Other 6

    1. Treat seizures as per normal, potential causes should be investigated.

    2. Maintenance anti-seizure therapy should be initiated after the first seizure.

    3. Consider reversible causes of cardiac arrest, as outlined in the Adult Cardiac Arrest CPG



All ROSC patients should ideally be transported to a receiving facility with a full intensive care unit. All receiving facilities should receive pre-notification that you are enroute with a ROSC patient.

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