Patient handout

Post-cardiac-arrest care (ROSC bundle)

PRODUCTION

1. Your condition

This handout is for post-cardiac-arrest care (rosc bundle). Your care team identified this based on: return of spontaneous circulation after cardiac arrest (aha 2020).

Other reasons your team may use this plan: comatose after rosc (not following commands) (aha 2020); stemi on post-rosc ecg (aha 2020); ohca with shockable initial rhythm (vf/pvt) (ttm2 dankiewicz nejm 2021).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
sedation_for_ttm	Propofol 25-100 mcg/kg/min IV titrate	IV	continuous	Sedation prevents shivering and dyssynchrony during cooling
fentanyl_for_ttm	0.5-2 mcg/kg/h IV	IV continuous	continuous	Adjunct to propofol; analgesic component of sedation

Plan: Post-ROSC bundle — TTM + hemodynamic optimization + ventilation + reperfusion + sedation

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Recovery — patient awake, following commands within 72 h

If you have:

GCS motor 6 within 72 h (ERC-ESICM 2021)
Following commands (AHA 2020)
Off vasopressors (AHA 2020)
Extubated or weaning (AHA 2020)

Do this:

Continue rehabilitation pathway (AHA 2020)
Cardiology follow-up for ICD/CRT eligibility (40-day waiting period for primary prevention) (AHA 2020)
Outpatient cardiac rehab + neurology follow-up (AHA 2020)
PICS (post-intensive care syndrome) screening at 1, 3, 6 months (SCCM 2012)
Family education on warning signs (recurrent arrhythmia, syncope) (AHA 2020)
Driving restrictions per local laws (typically 6 months post-arrest) (AHA 2020)

YELLOW — Uncertain prognosis — ongoing TTM, multimodal evaluation pending

If you have:

Comatose (AHA 2020)
TTM in progress (TTM2 Dankiewicz NEJM 2021)
Awaiting 72h neuroprognostication (ERC-ESICM 2021)
Sedation cleared but exam evolving (ERC-ESICM 2021)

Do this:

Daily family update meetings (AHA 2020)
Document GOC discussions (AHA 2020)
Continue full support pending prognostication (ERC-ESICM 2021)
Avoid premature withdrawal (ERC-ESICM 2021)
Multidisciplinary input — neurology, cardiology, palliative care (AHA 2020)

Call your provider if:

Family questions about prognosis or treatment (AHA 2020)
Goals-of-care conflict among family members (AHA 2020)

RED — Poor neuroprognosis — withdrawal of life-sustaining therapy

If you have:

Multimodal neuroprognostication consistent with poor outcome (ERC-ESICM 2021)
No motor response (ERC-ESICM 2021)
Burst-suppression EEG without sedation (ERC-ESICM 2021)
Brainstem reflexes absent (ERC-ESICM 2021)
NSE high (ERC-ESICM 2021; Nielsen NEJM 2013)
Bilateral SSEP absence (ERC-ESICM 2021)

Do this:

Family meeting with neurology, palliative care (AHA 2020)
Honor prior advance directive if applicable (AHA 2020)
WLST per family wishes — comfort measures, extubation, organ donation discussion (AHA 2020)
Bereavement support for family (AHA 2020)
Document organ donation discussion (separate consent) (AHA 2020)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

GCS <9 (or motor response <5) post-ROSC and not following commands (AHA 2020)
STEMI pattern on post-ROSC 12-lead ECG (AHA 2020)(life-threatening)
Refractory shock despite norepi >0.5 mcg/kg/min + vasopressin + hydrocortisone OR re-arrest (AHA 2020)(life-threatening)
Core temperature >37.7 deg C at any time post-ROSC (ERC-ESICM 2021)
Cerebral edema on CT, brainstem reflex loss, malignant EEG pattern (ERC-ESICM 2021)(life-threatening)
GOC discussion at 72h after multimodal neuroprognostication (ERC-ESICM 2021)

5. Follow-up

Rehabilitation referral, cardiology follow-up (ICD/CRT eligibility), neurology if anoxic injury, PICS screening, family + GOC continuity (AHA 2020; ERC-ESICM 2021)

6. Sources

Guideline: 2020 AHA Post-Cardiac-Arrest Care (Panchal Circulation 2020) + ERC-ESICM 2021 Post-Resuscitation Care (Nolan ICM 2021) + TTM2 (Dankiewicz NEJM 2021) + HYPERION (Lascarrou NEJM 2019) + COACT (Lemkes NEJM 2019) + TOMAHAWK (Desch NEJM 2021) + ARREST (Yannopoulos Lancet 2020 — ECMO eCPR); 2024 AHA focused update on adult ACLS