Post Cardiac Arrest Management

Hey Team,

I wanted to link you to several resources worth reviewing after our resuscitation a few days ago. 

• Tamis-Holland, J. E., et al. Cardiac Catheterization Laboratory Management of the Comatose Adult Patient With an Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation, 149(5), e274–e295. [pubmed]

  1. This is a scientific statement published in 2024 that has an extensive discussion regarding when and to when not to go to the cath lab.

• Post-Arrest Cardiac Cath EMRAP Episode: https://www.emrap.org/episode/worstcasescenar/cardiologycorne5

  1. This is a cardiology corner episode that reviews this scientific statement in some but not all detail.

• Hirsch, K. G., et al. Part 11: Post-Cardiac Arrest Care: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 152(16_suppl_2), S673–S718. [pubmed]

  • This is the Post-Cardiac Arrest Chapter of the AHA 2025 ACLS/Cardiac Arrest Guidelines. Lot's of good stuff here. 

• Post-Cardiac Arrest Care EMRAP Episode: https://www.emrap.org/episode/paceyourself/critbitspostcar

  1. This is a "Crit Bits" episode that reviews this AHA chapter in some but not all detail.

There is quite a bit to read through and listen to here. But definitely worth it to up your post-cardiac arrest game. 

Key Points:

Post-ROSC cath lab decisions (no STE)

• No routine immediate cath for all comatose post-ROSC patients without ST-elevation. Contemporary trials (e.g. COACT, TOMAHAWK) and AHA guidance support a selective strategy.

• However, emergent/urgent cath is reasonable when there is ongoing concern for an ischemic culprit despite no STE: recurrent VT/VF, cardiogenic shock, dynamic ischemic ECG changes, refractory instability, or high pretest probability of acute coronary occlusion (chest pain before arrest).

• Do not use early neurologic exam or perceived poor prognosis to exclude cath. Early neurologic findings are unreliable, frequently confounded by hypoxia, sedation, paralysis, and post-arrest encephalopathy, and should not drive cath decisions.

• AHA “poor prognostic indicators” that could play a role in cath decision if no STE: unwitnessed arrest, non-shockable initial rhythm, prolonged no-flow or low-flow time, severe metabolic acidosis or lactatemia, advanced age, and significant comorbid illness. Importantly, the AHA emphasizes these are associations, not definitive predictors.

Source:AHA Guidelines 2025

Neuroprognostication pearls:

• Avoid early prognostication. Formal neurologic prognostication should occur ≥72 hours after ROSC and after rewarming (If TTM used), with sedatives and paralytics cleared.

• Multimodal only. Prognosis should integrate serial neurologic exams, EEG, imaging, and biomarkers. No single test or early finding is sufficient.

Source: AHA Guidelines 2025

Other Post-arrest care recommendations:

• Physiology first. Target adequate cerebral perfusion with MAP goals typically ≥65 mmHg, avoid hypoxia and hyperoxia, prevent fever,  target normocapnia, control glucose, and identify and treat seizures.

Cheers,

Dillon