EMTprep Free Training Materials

What are four signs that you have ROSC (Return of Spontaneous Circulation)?

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There is a sudden increase EtCO2, pt begins spontaneously moving, pt begins to breathe on their own, pt has a pulse after an organized rhythm is detected.

Why will we see a change in EtCO2 if we have ROSC?

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When a patient is in cardiac arrest they are no longer having cellular metabolism or respiration, therefore we have a low end tidal because Oxygen and Carbon Dioxide are not being exchanged. The Carbon Dioxide is offloaded from the cells into the blood stream and then from the bloodstream into the lungs, so when more exchange takes place there is more in the lungs to be detected. Once the body is circulating blood again cellular metabolism and respiration occur again leading to a higher end tidal.

Why will the patient begin to move on their own?

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Often times when the brain is being perfused again it is able to send signals to the muscles that tells them to move, this is not happening when there is no circulation.

Why will the patient begin to breathe on their own?

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This one again comes down to perfusing the brain. The respiratory center lives in the brainstem which is typically the first place that gets perfused when the circulation resumes as it is the most essential area to maintain life. Once the brainstem is receiving Oxygenated blood it will tell the body to keep breathing. Sometimes during cardiac arrest a patient will continue to have agonal respirations that are not effective to keep the body oxygenated but once ROSC is achieved the respirations will increase and may even be effective enough to not need assistance, they should however still be monitored to ensure they are breathing effectively.

Why can there be electrical activity present during a cardiac arrest without a pulse, and how do we know when to check for a pulse?

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Cardiac arrest means that the heart is no longer able to contract hard enough or coordinated enough to create a pulse and actually perfuse the organs. This can be because there is increased pressure on the heart from a cardiac tamponade or tension pneumothorax, or because they took an overdose that impairs electrical conductivity in the heart, or because there is an occlusion in the coronary vessels or the lungs that is keeping oxygenated blood from reaching the cardiac tissue. The heart is a muscle that can die without getting adequate Oxygenation and waste removal. With that being said, there can still be electrical activity in the heart causing it to fibrillate or to fire too rapidly without being able to adequately fill and then contract to circulate the blood. We check for a pulse every time we see a change in electrical activity on the monitor.

What are the H’s and T’s that we look to correct or identify during a cardiac arrest to improve our chances of ROSC, how do we identify them, and how do we correct them?

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  • Hypoxia: low SpO2, ventilate with BVM and Oxygen
  • Hypothermia: low temperature, cover with a blanket
  • Hydrogen Ions: low EtCO2, Sodium Bicarb if it is in your scope of practice
  • Hyper/Hypokalemia: peaked T waves or widened QRS if Hyper and you can give Albuterol or Sodium Bicarb if in your scope of practice, decreased T waves or increased P waves or inversion of T waves with hypo, nothing we can do in the field, look for dialysis fistulas that may tell you they could have an abnormality with their potassium
  • Hypovolemia: bleeding, history of nausea, vomiting, diarrhea, give fluids


  • Toxins: sludge, constricted pupils, pill bottles or paraphernalia around, can give Narcan, Calcium, Sodium, or Glucagon if indicated for an overdose
  • Tension Pneumothorax: unequal chest rise, hyperinflation on one side of the chest, deviated trachea, do a needle decompression of the chest
  • Coronary/Pulmonary Thrombus: listen to the history, did they have chest pain, were they short of breath, nothing we can do in the field

Once you have ROSC what are some things that you should do that may help you determine why they went into cardiac arrest?

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Once you have ROSC you should do a 12lead to determine if they have had a STEMI that caused them to stop perfusing, you should also check their vitals to determine if they have a blood pressure high enough to continue perfusing or if they are likely to lose a pulse again. You can also listen to lung sounds to determine if they are fluid overloaded and not exchanging Oxygen and Carbon Dioxide well, or if they have pneumonia or asthma/COPD exacerbation.

What is the goal range for EtCO2, SpO2, and BP in ROSC?

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You want your EtCO2 to be between 35-45 mm/Hg, SpO2 to be 94% or above, and Systolic BP at 90 mm/Hg or above.

What do we do if we achieve ROSC and then we lose a pulse again?

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Continue where you left off when you obtained ROSC, give Epinephrine every 3-5 minutes, continue to evaluate and treat for your H’s and T’s, defibrillate if necessary, if you only gave one dose of Amiodarone and they can have another then give them that, you can also call the hospital to speak to a physician to make sure you are not missing anything or if they have any suggestions.

How would you manage a ROSC patient once you are transporting, how often do you take vitals, how often should you do a pulse check?

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When transporting a ROSC patient make sure to address all of your H’s and T’s, bring along another 1 or 2 people in case you lose a pulse again, make sure they are hooked up to the monitor, get vitals at least every 5 minutes, continue to monitor their HR and rhythm, BP, SpO2, EtCO2, if they have evidence of an MI or had chest pain prior to arresting then obtain serial 12leads to evaluate for changes, if you notice a drop in SpO2, EtCO2, increase or decrease in heart rate, or a rhythm change check for a pulse.