Once ROSC is achieved, the patient’s airway and ventilation should be ensured. If the patient is unconscious, advanced airway management is likely necessary. The bed should be angled at 30 degrees if possible to minimize cerebral edema, risk of aspiration, and pneumonia associated with mechanical ventilation. The security of the airway should always be ensured. Importantly, during ROSC, the goal oxygen saturation becomes 94% and above as excess oxygen can lead to toxicity. Ensure that there is not hyperventilation, which can lead to increased thoracic pressures and negatively affect preload and cardiac output.  Hyperventilation can also decrease blood flow to the brain due to decreased PaCO2. The goal should be PETCO2 between 35-40 mm Hg and PaCO2 between 40-45 mm Hg. 

Monitoring the patient’s vital signs is another critical evaluation following ROSC. This will include cardiac monitoring to evaluate for arrhythmias as well as blood pressure evaluation to ensure adequate systemic perfusion. The goal mean arterial pressures (MAP) should be 65 mm Hg and higher or systolic BP over 90 mm Hg. Adequate systemic blood pressure is necessary to maintain brain perfusion. 

Temperature management is known to benefit neurologic outcomes after cardiac arrest. Consequently, any patient who is unable to follow commands should be started on this therapy. The patient must be cared for in a center that routinely provides temperature management and other advanced therapies, including cardiac reperfusion. As ACS is a common underlying etiology of arrest, a 12 lead ECG must be obtained to rule out acute MI. Patients should be managed according to the algorithm for ACS if there is evidence of ACS, even if the patient remains comatose.  Reperfusion with PCI may still be considered in comatose patients in which there is a high index of suspicion for ACS, even in the absence of ST elevation. (Class IIa, Evidence level B-NR). PCI can be done in conjunction with temperature management. PCI is appropriate following arrest in appropriate candidates, whether awake or unconscious. (Class IIa, Evidence level C-LD).

During the first 72 hours following cardiac arrest, the extent of neurologic damage, or its resolution may not be fully known. Long-term prognosis cannot be evaluated until after this period. In the patient who requires sedation or has altered consciousness for other reasons, the time to determine prognosis may be extended.