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A lot of content in ACLS training courses focuses on learning and applying the rhythm-based algorithms, and return of spontaneous circulation (ROSC) is a favorable outcome of those processes. When a patient reaches ROSC, the team reaches a new stage of care in the ACLS algorithm.
For an ACLS team, ROSC is cause to celebrate! It means that life-saving interventions have produced some results. However the team must still proceed carefully and follow evidenced-based interventions to manage this new phase. Learning more about ROSC is important for ACLS clinicians to understand the entire continuum of care and how to optimize patient outcomes.
Return of spontaneous circulation (ROSC) is defined as “the resumption of sustained perfusing cardiac activity associated with significant respiratory effort after cardiac arrest.” Team members continuously assess for ROSC by observing the patient’s color, any movement, respiratory effort, and by frequently checking for a pulse.
It is important to understand that while ROSC is an event, it is also a phase of care that is unstable and requires team action. In other words, while the initial goal is accomplished — don’t make the mistake of thinking the ACLS event is over.
The signs that indicate ROSC will be first observed in the patient and then verified by vital signs and cardiac monitoring. Patient spontaneous movement, coughing, sustained breathing, a palpable pulse, and measurable blood pressure all indicate ROSC. Although these signs are indicative that resuscitation efforts have been successful, remember that the patient is still unstable, the cause of the initial arrest may still be present. Plus, the patient likely has multiple medications circulating in their system that will begin to wear off.
It is also important to understand that ROSC is not necessarily a linear process. Patients can reach ROSC and then revert back into cardiac arrest. They may even do so multiple times until the underlying cause is corrected. The ACLS team should be able to quickly pivot back to the correct ACLS algorithm based on the patient’s cardiac rhythm.
One interesting phenomenon that can occur (although rarely) is called the Lazarus phenomenon. The phenomenon is defined as the delayed return of ROSC after CPR has ceased.
There are at least 38 reported cases of this happening since 1982 when the phenomenon was first described in the literature. These anecdotes describe patients “waking up” minutes or even hours after being declared dead — and around 45% of them experienced good neurological recovery. Theories to explain this vary. Delayed action of uncirculated medications is one theory, while a buildup of pressure in the chest from CPR kickstarting the heart is another. The truth is, there is no great explanation for why this occurs.
Several ACLS situations involve loss of circulation, particularly ventricular tachycardia (VT), ventricular fibrillation (VF), pulseless electrical activity (PEA), and asystole. Other conditions that activate an ACLS response, like supraventricular tachycardia (SVT), bradycardia, atrial fibrillation, and various blocks may be symptomatic and require a response, while there is no loss of circulation (pulse and measurable blood pressure).
Clearly, the patient in cardiac arrest with no pulse is in dire straits. It is up to the clinical team to provide the quality CPR and ACLS care that gives the patient the best possible chance at ROSC.
At the point that an ACLS response to cardiac arrest is in progress, there are always two possible outcomes: ROSC, or no ROSC. In that, there are important things that the team can do to maximize the patient’s chance of ROSC and a favorable post-ROSC outcome.
Now that the patient has reached ROSC, the real work begins. This phase of care is critical to the patient’s long-term chances of survival. Unfortunately, up to two-thirds of patients with return of spontaneous circulation do not survive long enough to be discharged from the hospital. To increase the chances for survival, it’s critical to take quick action according to the best practices.
The ACLS Post-Cardiac Arrest Care Algorithm begins with ROSC and divides subsequent activities into two phases:
Additionally, the algorithm reminds the team to evaluate and treat rapidly reversible causes, commonly termed the “H’s and T’s” for easy recall.
ACLS-trained clinicians should also be aware of post-cardiac arrest syndrome, a complex set of pathophysiological processes that happens after ROSC. Because of this syndrome, careful ICU monitoring should be in place to watch for the following:
Each facility should have an easily accessible ROSC policy and procedure, usually accompanied by a care plan and checklist. Each member of the ACLS team should be very familiar with the facility’s processes and understand their role(s).
All organizational post-ROSC plans of care should include the following components:
Post-ROSC care has been adjusted over the years as new studies emerge, and will likely continue to evolve. The goal of ROSC is always to promote the best possible long-term outcomes for the patient, and there are various sources of information on how to accomplish that.
Some of the current topics being studied in relation to ROSC are:
It is easy to become overloaded with information when learning about ROSC and post-resuscitation care. After all, there are a lot of scenarios to think about and a lot of interventions needed. It is important for ACLS clinicians to remember the basics — always using high-quality CPR, following the ACLS algorithms, and practicing effective team dynamics to give the patient the best possible chance for attaining ROSC. Rather than an end goal, ROSC should be considered a milestone. From there, even more work begins to monitor the patient’s hemodynamic status and seek to optimize outcomes.
If you would like to learn more about the drugs, ECG rhythms, clinical scenarios, and other topics related to ACLS, AMRI has study materials to help you develop a better understanding. Accredited by the National Board of Emergency Care Certifications (NBECC), AMRI has helped more than one million medical professionals become certified or recertified in ACLS, BLS, and PALS since 1983.
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