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HLT-EMT39-03 · Lesson 9 · 32 clock hours · practice

Cardiac Arrest Resuscitation and Post-Resuscitation Care

Objective. Learner will lead and participate in team-based cardiac arrest resuscitation scenarios applying high-quality CPR, the cardiac arrest algorithm, and structured post-ROSC care according to current resuscitation science.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

VoTechWorks program approval and accreditation are still in progress. Credentials are issued only by the certifying bodies named in each program, after their own exams.

Cardiac Arrest Resuscitation and Post-Resuscitation Care

Cardiac arrest is one of the most time-critical emergencies you will face in EMS. Survival depends on a coordinated team performing high-quality CPR, rapidly identifying and treating shockable rhythms, and delivering structured care after return of spontaneous circulation (ROSC). This lesson brings together the skills and knowledge from the cardiac emergencies course into real-world team practice.

Scene Safety and Initial Actions

Before touching the patient, confirm scene safety. Once safe, establish unresponsiveness, confirm absent or agonal breathing, and check for a pulse simultaneously for no more than 10 seconds. If cardiac arrest is confirmed, activate your EMS system, retrieve the defibrillator, and begin CPR immediately. Every second without compressions reduces the chance of survival.

High-Quality CPR: The Foundation of Resuscitation

High-quality CPR means compressions at the correct rate (100–120 per minute), adequate depth (at least 2 inches in adults, no more than 2.4 inches), full chest recoil between compressions, and minimal interruptions. Avoid leaning on the chest between compressions — leaning prevents the heart from refilling. Keep CPR pauses to under 10 seconds for any single interruption (rhythm check, pulse check, shock delivery, or airway placement).

Rescuer fatigue degrades compression quality within two minutes. Rotate the compressor role every two minutes, coordinating switches during rhythm checks to minimize downtime. A CPR-feedback device gives you real-time data on rate and depth — use it to self-correct rather than guessing.

Ventilation rate in a patient without an advanced airway is 30 compressions to 2 breaths. Once an advanced airway is placed (supraglottic airway or endotracheal tube), deliver continuous compressions and ventilate at approximately 10 breaths per minute. Avoid hyperventilation — excessive ventilation rate raises intrathoracic pressure, reduces coronary perfusion pressure, and worsens outcomes.

The Cardiac Arrest Algorithm

All cardiac arrest rhythms fall into two categories: shockable (ventricular fibrillation and pulseless ventricular tachycardia) and non-shockable (pulseless electrical activity and asystole).

For shockable rhythms: deliver a shock as quickly as possible, then immediately resume CPR for two minutes before rechecking the rhythm. For non-shockable rhythms: continue CPR and treat reversible causes. Epinephrine is used in cardiac arrest for both shockable and non-shockable rhythms according to your medical director's protocols and current resuscitation guidelines — know your local protocol intervals.

The Hs and Ts are the reversible causes every provider must memorize:

Addressing a reversible cause may be the intervention that achieves ROSC.

Team Leadership During Resuscitation

As team leader, you direct without doing compressions — this keeps your eyes on the whole picture. Assign roles clearly: compressor, airway manager, monitor/defibrillator operator, IV/IO and medication provider, and recorder. Use closed-loop communication: give a directive, have the team member repeat it back, then confirm completion. Limit unnecessary chatter. Call out rhythm findings so the whole team hears them. Announce compression switches at least one cycle in advance.

Document CPR pause times and medication times as you go. After the call, a structured debriefing using real performance data — manikin feedback reports or video review — is the most effective way to improve team performance.

Post-ROSC Care in the Prehospital Setting

When ROSC is achieved, the resuscitation is not over. The post-cardiac arrest period is high-risk for re-arrest and secondary organ injury. Your priorities:

Oxygenation: Titrate oxygen to maintain SpO₂ in the range recommended by current guidelines (generally 94–99%). Avoid both hypoxia and prolonged hyperoxia.

Ventilation: Target a normal EtCO₂ range to avoid hypocapnia (which causes cerebral vasoconstriction) and hypercapnia. Monitor waveform capnography continuously.

Blood pressure: Hypotension after ROSC worsens neurological outcomes. Support blood pressure with fluids and vasopressors as protocol allows, targeting a mean arterial pressure consistent with current guidelines and your medical director's direction.

Targeted Temperature Management (TTM): For patients who remain unconscious after ROSC, preventing fever and considering TTM is part of the post-arrest bundle. Prehospital providers should avoid active warming of the post-arrest patient who is normothermic or hypothermic unless specifically directed otherwise, and report the patient's temperature to the receiving hospital.

Reassessment: Perform a thorough reassessment — 12-lead ECG for STEMI identification, reassess airway security, repeat vital signs frequently, and communicate a full hand-off to the receiving team. Re-arrest can occur at any moment; keep your defibrillator immediately available.

Safety Points

Key terms10

Return of Spontaneous Circulation (ROSC)Resumption of a perfusing cardiac rhythm detected by a palpable pulse or measurable blood pressure, indicating successful resuscitation from cardiac arrest.
High-Quality CPRChest compressions delivered at 100–120 per minute, to an adequate depth, with full chest recoil, minimal interruptions, and no excessive ventilation rate.
Ventricular Fibrillation (VF)A chaotic, disorganized shockable cardiac rhythm in which the ventricles quiver without coordinated contraction, producing no pulse.
Pulseless Ventricular Tachycardia (pVT)A rapid, organized ventricular rhythm that produces no effective cardiac output and no palpable pulse; treated the same as ventricular fibrillation with immediate defibrillation.
Pulseless Electrical Activity (PEA)A non-shockable cardiac arrest rhythm in which organized electrical activity is present on the monitor but no pulse is palpable; treatment focuses on CPR and reversible causes.
Hs and TsA memory aid for the reversible causes of cardiac arrest: Hypoxia, Hypovolemia, Hydrogen ion, Hypo/Hyperkalemia, Hypothermia; Tension pneumothorax, Tamponade, Toxins, Thrombosis.
Targeted Temperature Management (TTM)A post-resuscitation strategy of actively controlling a comatose ROSC patient's body temperature to a target range specified by current guidelines and the receiving hospital, intended to reduce secondary brain injury.
Closed-Loop CommunicationA team communication technique in which the team leader gives a directive, the assigned member repeats it back, and the leader confirms — reducing errors during high-stress resuscitations.
CPR Pause IntervalThe time during which chest compressions are interrupted; current guidelines recommend keeping any single pause to under 10 seconds to preserve coronary perfusion pressure.
End-Tidal CO₂ (EtCO₂)The concentration of carbon dioxide measured at the end of exhalation, used in cardiac arrest to confirm airway placement, assess CPR quality, and detect ROSC.
In class: As team leader, manage a full cardiac arrest simulation including scene safety, team role assignment, high-quality CPR (rate, depth, recoil, minimal interruptions), rhythm interpretation, defibrillation, medication administration decisions, and airway management, with an instructor timing all CPR pauses and providing debriefing using recorded performance data. · As a team member performing CPR, demonstrate correct compression rate and depth on a CPR-feedback manikin for two minutes and review real-time feedback data to self-correct technique, rotating roles every two minutes across three full arrest cycles. · Develop a written post-ROSC care plan for a simulated patient who achieves return of spontaneous circulation, addressing targeted temperature management considerations, blood pressure targets, oxygenation goals, and reassessment priorities in the prehospital setting.
Materials: CPR-feedback manikin (with real-time rate/depth display), high-fidelity cardiac arrest simulator, defibrillator, airway management equipment, cardiac arrest algorithm reference card, stopwatch, post-ROSC care worksheet, video debriefing capability if available
Check: Learner achieves CPR quality metrics of correct rate and adequate depth on at least 80% of compressions per manikin feedback report; no critical errors (e.g., missed shockable rhythm, ventilation rate exceeding recommended maximum) on the scenario checklist; 80% overall scenario score required to pass.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Cardiology / Resuscitation
1. During a cardiac arrest, you are the team leader. After two minutes of CPR, the monitor displays ventricular fibrillation. What is your immediate next action?
Cardiology / Resuscitation
2. A CPR-feedback manikin shows your compressions are averaging 90 per minute with 2.1-inch depth. Which correction should you make first?
Cardiology / Resuscitation
3. Your patient achieves ROSC after 18 minutes of cardiac arrest. She remains unresponsive. Her SpO₂ reads 100% on high-flow oxygen and her ventilation rate is 20 breaths per minute via BVM through a supraglottic airway. What should you correct?
Cardiology / Resuscitation
4. During a resuscitation, the monitor shows a narrow, organized rhythm at 70 per minute but the patient has no palpable pulse. Which rhythm category does this represent, and what is the treatment priority?
Cardiology / Resuscitation
5. Which of the following best describes the recommended maximum duration for any single CPR pause during cardiac arrest resuscitation?
Cardiology / Resuscitation
6. A patient in cardiac arrest is found to have distended neck veins, absent breath sounds on the left, and tracheal deviation to the right. Which reversible cause of cardiac arrest does this presentation most suggest?
EMS Operations / Teamwork
7. You are directing a resuscitation team. You tell the medication provider, 'Prepare and administer epinephrine per protocol.' The provider says nothing and begins drawing up the medication. What is the error in this exchange?
Cardiology / Resuscitation
8. After ROSC, your post-arrest patient's systolic blood pressure is 70 mmHg and he remains unconscious. Which post-ROSC care priority does this finding most directly address?
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