Step 1 · Emergency
Arrest recognition
- Unresponsive + abnormal/absent breathing + no definite pulse → CPR
- High-quality compressions with minimal pauses
- Defibrillate VF/pulseless VT promptly; use rhythm-appropriate ALS
cardiovascular / hemodynamic
Cardiac Arrest, Peri-Arrest & Post-ROSC Deterioration
Recognize cardiac arrest or peri-arrest physiology, deliver high-quality ALS, treat reversible causes, then stabilize oxygenation, ventilation, perfusion and temperature after ROSC.
CLINICAL ALGORITHMMedically Verified (2026-09-15)
Cardiac arrest to post-ROSC: resuscitation continues after the pulse returns
Level: Controlled React algorithm
Visual bedside algorithm
Cardiac arrest to post-ROSC: resuscitation continues after the pulse returns
Step 2 · Assess / decide
Treat reversible causes
- Hypovolemia/hemorrhage, hypoxemia, severe acidosis/electrolyte disorder, hypothermia
- Tension pneumothorax, tamponade, toxins, pulmonary thrombosis and coronary thrombosis
- Waveform capnography with an advanced airway
Step 3 · Treat
After ROSC
- Avoid hypoxemia and unnecessary hyperoxemia
- Target appropriate ventilation; avoid routine hyperventilation
- Defend perfusion with individualized hemodynamic support
- 12-lead ECG + evaluate coronary and non-coronary causes
Step 4 · Escalate / reassess
Post-arrest bundle
- Temperature-control strategy and fever prevention when unresponsive
- Treat seizures and metabolic derangements
- Reassess recurrent shock/arrhythmia with echo when useful
- Delay definitive neuroprognostication; use appropriately timed multimodal assessment
Bedside bottom line
ROSC is a transition, not an endpoint. Recurrent hypotension, hypoxemia, arrhythmia or rising lactate means ongoing post-arrest shock until proven otherwise.
Recognize arrest / peri-arrest
If the patient is unresponsive with absent or abnormal breathing and no definite pulse, start CPR immediately. In a deteriorating patient who still has a pulse, identify unstable bradyarrhythmia/tachyarrhythmia, profound shock, severe hypoxemia or another reversible pre-arrest state before circulatory arrest occurs.
Act now — arrest
Prioritize high-quality CPR with minimal interruptions, immediate defibrillation for VF/pulseless VT, appropriate epinephrine timing and rhythm-specific antiarrhythmic therapy. Secure oxygenation/ventilation without interrupting compressions and use waveform capnography when an advanced airway is placed.
Reversible causes
Actively search for and treat reversible causes in parallel: hypovolemia/hemorrhage, hypoxemia, hydrogen-ion excess/severe metabolic derangement, hypo-/hyperkalemia and other electrolytes, hypothermia, tension pneumothorax, tamponade, toxins, pulmonary thrombosis and coronary thrombosis.
After ROSC
Temperature / neuroprognostication
Escalate
Caution
A transient ROSC is not the end of resuscitation. Recurrent hypotension, hypoxemia, arrhythmia or rising lactate after ROSC should be treated as ongoing post-arrest shock while the reversible cause is pursued.
Direct evidence for this problem
2 sourcesguideline•2025
Part 9: Adult Advanced Life Support: 2025 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care ↗Current adult advanced-life-support guidance for arrest and peri-arrest management.
guideline•2025
Part 11: Post-Cardiac Arrest Care: 2025 AHA Guidelines for CPR and ECC ↗Current AHA post-cardiac-arrest care, temperature-control and neuroprognostication guidance.
Evidence status
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Actionable Clinical Workflows (2)
Step-by-step ICU ProcessesRefractory Shock Support Escalation
From multi-vasopressor failure to rescue non-adrenergic agents and mechanical circulatory support.
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Maternal Critical Illness Rapid AssessmentUrgent maternal stabilization, left uterine displacement, syndromic differentiation, and multidisciplinary escalation.
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