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cc.post-arrest-care.core.v1PRODUCTION
cc.post-arrest-care.core.v1

Post-cardiac-arrest care (ROSC bundle)

critical_careacuteadult
Hard-required inputs
0 / 15
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Establish post-arrest care scope; document arrest characteristics for prognosis (AHA 2020 Panchal)

Inputs
3
Actions
0
Advance rule
Set
Advance when

Arrest narrative captured (AHA 2020)

Patient inputs (18)

Older adults higher post-arrest mortality; goals-of-care discussion (AHA 2020 Panchal)

Witnessed + bystander CPR + rhythm dictates prognosis (AHA 2020)

Shockable (VF/pVT) vs non-shockable (asystole/PEA) — TTM and intervention decisions (TTM2 Dankiewicz NEJM 2021; HYPERION Lascarrou NEJM 2019)

Longer downtime → worse neurologic prognosis (AHA 2020)

Cardiac vs respiratory vs toxic vs neuro — drives workup (AHA 2020)

Tissue hypoperfusion + clearance trajectory (AHA 2020)

Severity of post-arrest acidosis (AHA 2020)

Cardiac etiology + STEMI/NSTEMI workup (AHA 2020)

AKI common post-arrest; renal-dose abx if shock (AHA 2020)

Arrhythmogenic; correct to 4–4.5 mmol/L (AHA 2020)

STEMI → emergent cath; COACT Lemkes NEJM 2019: non-STEMI benefit absent

ETT placement, pulmonary edema, aspiration (AHA 2020)

MAP ≥65 target; vasopressor titration (AHA 2020; ERC-ESICM 2021)

TTM target 33°C vs 37.5°C per TTM2 (Dankiewicz NEJM 2021)

AVOID hyperoxia — target SpO2 92–98% (AHA 2020; ERC-ESICM 2021)

Rule out intracranial cause / cerebral edema (AHA 2020; ERC-ESICM 2021)

LV function, RV strain, tamponade, valvular cause (AHA 2020)

Multimodal neuroprognostication delayed ≥72 h (ERC-ESICM 2021; AHA 2020)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningstemi_on_post_rosc_ecg (AHA 2020)
    STEMI pattern on post-ROSC 12-lead ECG (AHA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_shock_or_rearrest (ARREST Yannopoulos 2020)
    Refractory shock despite norepi >0.5 mcg/kg/min + vasopressin + hydrocortisone OR re-arrest (AHA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcerebral_edema_signs (ERC-ESICM 2021)
    Cerebral edema on CT, brainstem reflex loss, malignant EEG pattern (ERC-ESICM 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecomatose_post_rosc_GCS_under_9 (AHA 2020)
    GCS <9 (or motor response <5) post-ROSC and not following commands (AHA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehyperthermia_or_rewarming_overshoot (ERC-ESICM 2021)
    Core temperature >37.7 deg C at any time post-ROSC (ERC-ESICM 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefamily_goc_conflict_or_alignment_for_WLST (AHA 2020)
    GOC discussion at 72h after multimodal neuroprognostication (ERC-ESICM 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehyperoxia_or_hypocapnia (AHA 2020; ERC-ESICM 2021)
    PaO2 >200 OR PaCO2 <35 on post-ROSC ABG (AHA 2020; ERC-ESICM 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Post-ROSC bundle — TTM + hemodynamic optimization + ventilation + reperfusion + sedation
axis: post_rosc_bundlestep 1 - Step 1 — Targeted temperature management (TTM 32-36°C × 24h or strict normothermia 37.5°C)
Selected step "Step 1 — Targeted temperature management (TTM 32-36°C × 24h or strict normothermia 37.5°C)" — ROSC + comatose (GCS <9 or not following commands) + no severe contraindication (active bleeding, refractory shock)
  • sedation_for_ttm
    first line
    sedative
    Propofol 25-100 mcg/kg/min IV titrate • IV • continuous
    triggers: TTM_active, shivering_during_cooling
    Sedation prevents shivering and dyssynchrony during cooling
    rxcui 8782
  • fentanyl_for_ttm
    first line
    opioid
    0.5-2 mcg/kg/h IV • IV continuous • continuous
    triggers: TTM_active
    Adjunct to propofol; analgesic component of sedation
    rxcui 4337

ed playbook — drug actions (5)

  1. 1. norepinephrine
    rxcui 7512
    0.05-0.5 mcg/kg/min IV titrated to MAP ≥65 • IV continuous • continuous
    trigger: MAP <65 after fluid
    AHA 2020 first-line vasopressor
  2. 2. cold_saline_bolus
    rxcui 313002
    20-30 mL/kg cold NS • IV • rapid bolus
    trigger: Initiating TTM if cooling device not yet in place
    Bridge to surface/intravascular cooling device
  3. 3. sedation_propofol_fentanyl
    Propofol 25-100 mcg/kg/min + fentanyl 0.5-2 mcg/kg/h • IV continuous • continuous
    trigger: Intubated + cooling
    Sedation for ventilator + cooling
  4. 4. amiodarone_for_recurrent_VT_VF
    rxcui 703
    150-300 mg IV bolus then drip • IV • bolus + 24-h drip
    trigger: Recurrent shockable arrhythmia
    AHA 2020 — antiarrhythmic for recurrent shockable rhythms
  5. 5. magnesium_for_torsades
    rxcui 6585
    2 g IV • IV • bolus
    trigger: Torsades de pointes / hypomagnesemia
    Mg replete + arrhythmia treatment

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Return of spontaneous circulation after cardiac arrest (AHA 2020); Comatose after ROSC (not following commands) (AHA 2020); STEMI on post-ROSC ECG (AHA 2020).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Post-cardiac-arrest care (ROSC bundle)** (cc.post-arrest-care.core.v1).
Phenotype framing: ACS, PE, tamponade, tension PTX, hyperkalemia/electrolyte, hypoxia, hypothermia, tox, trauma, ICH, sepsis-arrest (AHA 2020 5H/5T)
Scope: Establish post-arrest care scope; document arrest characteristics for prognosis (AHA 2020 Panchal)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Post-ROSC bundle — TTM + hemodynamic optimization + ventilation + reperfusion + sedation** — step "Step 1 — Targeted temperature management (TTM 32-36°C × 24h or strict normothermia 37.5°C)".
1. sedation_for_ttm Propofol 25-100 mcg/kg/min IV titrate IV continuous (sedative, first line) — Sedation prevents shivering and dyssynchrony during cooling
2. fentanyl_for_ttm 0.5-2 mcg/kg/h IV IV continuous continuous (opioid, first line) — Adjunct to propofol; analgesic component of sedation

Setting playbook (ed) — Stabilize hemodynamics, secure airway, identify cardiac etiology (STEMI), initiate TTM, transfer to ICU/cath/ECMO (AHA 2020; ERC-ESICM 2021)
3. norepinephrine 0.05-0.5 mcg/kg/min IV titrated to MAP ≥65 IV continuous continuous — MAP <65 after fluid (AHA 2020 first-line vasopressor)
4. cold_saline_bolus 20-30 mL/kg cold NS IV rapid bolus — Initiating TTM if cooling device not yet in place (Bridge to surface/intravascular cooling device)
5. sedation_propofol_fentanyl Propofol 25-100 mcg/kg/min + fentanyl 0.5-2 mcg/kg/h IV continuous continuous — Intubated + cooling (Sedation for ventilator + cooling)
6. amiodarone_for_recurrent_VT_VF 150-300 mg IV bolus then drip IV bolus + 24-h drip — Recurrent shockable arrhythmia (AHA 2020 — antiarrhythmic for recurrent shockable rhythms)
7. magnesium_for_torsades 2 g IV IV bolus — Torsades de pointes / hypomagnesemia (Mg replete + arrhythmia treatment)

Non-pharmacologic actions:
- Endotracheal intubation if not already (most post-arrest patients are intubated) (AHA 2020)
- Lung-protective ventilation (TV 6 mL/kg PBW, plateau <30, PEEP 5-10, FiO2 to SpO2 92-98) (AHA 2020; ERC-ESICM 2021)
- Initiate TTM (32-36°C) target — surface or intravascular cooling (TTM2 Dankiewicz NEJM 2021; HYPERION Lascarrou NEJM 2019)
- Activate cath lab if STEMI; non-STEMI shockable per institutional protocol (COACT Lemkes NEJM 2019 did not show benefit of routine cath in non-STEMI)
- Echo at bedside for cause hypothesis (AHA 2020)
- Neurology consult for prognostication planning (ERC-ESICM 2021)
- Family conversation early — code status, GOC (AHA 2020)

AVOID / contraindication checks:
- Avoid_hyperoxia_target_SpO2_92 98 (AHA 2020; ERC ESICM 2021)
- Avoid_hypocapnia_PaCO2_35 45 (ERC ESICM 2021)
- K_management_during_cooling_and_rewarming_is_critical (AHA 2020)
- No_TTM_in_active_bleeding_or_refractory_shock (TTM2 Dankiewicz NEJM 2021)
- Neuroprognostication_delayed_at_least_72h_after_rewarming_off_sedation (ERC ESICM 2021)
- STEMI_emergent_cath_within_90min_routine_cath_for_non_STEMI_no_benefit (COACT Lemkes NEJM 2019)

Monitoring

Regimen monitoring:
- continuous core temp oesophageal or bladder (AHA 2020; ERC-ESICM 2021)
- continuous MAP arterial line (AHA 2020)
- SpO2 continuous target 92-98 (AHA 2020; ERC-ESICM 2021)
- capnography continuous target PaCO2 35-45 (ERC-ESICM 2021)
- EEG for seizure especially in TTM phase (ERC-ESICM 2021)
- q4h lactate K glucose (AHA 2020)
- q6h BMP during cooling rewarming (AHA 2020)
- q4h neuro exam after rewarming off sedation (ERC-ESICM 2021)
- multimodal neuroprognostication at 72h (ERC-ESICM 2021; Nielsen NEJM 2013)

Setting (ed) monitoring:
- Continuous core temp (AHA 2020)
- Continuous arterial line BP (AHA 2020)
- Continuous SpO2 + capnography (AHA 2020; ERC-ESICM 2021)
- Continuous ECG (AHA 2020)
- q1h labs (lactate, K, glucose) initially (AHA 2020)
- EEG hookup if seizure-prone (ERC-ESICM 2021)

Follow-up plan: Rehabilitation referral, cardiology follow-up (ICD/CRT eligibility), neurology if anoxic injury, PICS screening, family + GOC continuity (AHA 2020; ERC-ESICM 2021)
- Close-out criterion: Discharge plan + outpatient follow-up booked

Monitoring phase: Continuous core temp, MAP, SpO2, end-tidal CO2, EEG (esp. seizure-prone), serial lactate/ABG/BMP, neuro exam q4h after rewarming, multimodal neuroprognostication ≥72 h (ERC-ESICM 2021; AHA 2020)

Disposition

Current setting: ed — Stabilize hemodynamics, secure airway, identify cardiac etiology (STEMI), initiate TTM, transfer to ICU/cath/ECMO (AHA 2020; ERC-ESICM 2021)

Disposition criteria:
- ICU admission mandatory for any post-arrest patient (AHA 2020)
- Cath lab if STEMI (AHA 2020)
- Cardiothoracic if MCS needed (ARREST Yannopoulos 2020)
- Transfer if no PCI / ECMO on site (AHA 2020)

Escalation triggers (move to higher acuity):
- STEMI → cath lab within 90 min (AHA 2020)
- Refractory shock → MCS (Impella/ECMO) consideration (ARREST Yannopoulos 2020)
- Re-arrest → ACLS + ECMO standby (AHA 2020)
- Refractory hypoxaemia despite max vent → ECMO (AHA 2020)
- Cerebral edema / brainstem signs → neurosurgery / hypertonic (ERC-ESICM 2021)

Patient Action Plan

**Post-arrest family communication + advance care planning**
Personalised values: initial_rhythm, time_to_rosc_min, prior_advance_directive, family_decision_maker, comorbidities.

**Recovery — patient awake, following commands within 72 h** (green):
Triggers:
- GCS motor 6 within 72 h (ERC-ESICM 2021)
- Following commands (AHA 2020)
- Off vasopressors (AHA 2020)
- Extubated or weaning (AHA 2020)
Actions:
- 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)

**Uncertain prognosis — ongoing TTM, multimodal evaluation pending** (yellow):
Triggers:
- Comatose (AHA 2020)
- TTM in progress (TTM2 Dankiewicz NEJM 2021)
- Awaiting 72h neuroprognostication (ERC-ESICM 2021)
- Sedation cleared but exam evolving (ERC-ESICM 2021)
Actions:
- 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)
Contact provider when:
- Family questions about prognosis or treatment (AHA 2020)
- Goals-of-care conflict among family members (AHA 2020)

**Poor neuroprognosis — withdrawal of life-sustaining therapy** (red):
Triggers:
- 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)
Actions:
- 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)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] Cerebral edema on CT, brainstem reflex loss, malignant EEG pattern (ERC-ESICM 2021)

Citations

- 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 [PMID:34133859](https://pubmed.ncbi.nlm.nih.gov/34133859/)
- Cited evidence (PMID 31577396) [PMID:31577396](https://pubmed.ncbi.nlm.nih.gov/31577396/)
- Cited evidence (PMID 30883057) [PMID:30883057](https://pubmed.ncbi.nlm.nih.gov/30883057/)
- Cited evidence (PMID 34459570) [PMID:34459570](https://pubmed.ncbi.nlm.nih.gov/34459570/)
- Cited evidence (PMID 33197396) [PMID:33197396](https://pubmed.ncbi.nlm.nih.gov/33197396/)

Last reconciled with current guidelines: 2026-05-12.
References
  • 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 — PMID:34133859
  • Cited evidence (PMID 31577396) — PMID:31577396
  • Cited evidence (PMID 30883057) — PMID:30883057
  • Cited evidence (PMID 34459570) — PMID:34459570
  • Cited evidence (PMID 33197396) — PMID:33197396