MDCAST | ROSC and Roll: Post-Arrest Care in Transport

This episode of the FlightBridgeED podcast focuses on post-cardiac arrest care during critical care transport, particularly for crews moving patients from outside or critical access hospitals to higher levels of care. Dr. Mike Lauria frames the post-ROSC patient around a simple mental model: help the heart, hunt for the cause, sustain the brain, and then provide all the other good critical care support needed during transport. While not all post-arrest patients are the same, this framework helps crews prioritize the problems most likely to affect survival and neurologic outcome. The first priority is stabilizing the cardiovascular system. After ROSC, crews should consider securing a definitive airway, especially if the patient is stable enough to safely exchange a supraglottic airway for an endotracheal tube. Perfusion should be optimized with a MAP goal around 65, cautious fluid administration, and early use of vasopressors when needed. Norepinephrine is presented as a reasonable first-line pressor, with epinephrine added when there is evidence of poor contractility or a need for inotropic support. The episode also emphasizes the usefulness of arterial lines, repeat EKGs, and point-of-care ultrasound when available, while cautioning against delaying transport for interventions that are not essential. A major theme is that crews must continue to search for the cause of the arrest even after ROSC. The H’s and T’s still matter, and transport teams may have access to critical information that can disappear during the handoff chain. Speaking directly with family, bystanders, or the sending team can uncover symptoms or events that change the patient’s trajectory. The episode also highlights the risk of re-arrest, noting that pads should stay on, ACLS medications should remain immediately available, and crews should stay alert for reversible causes, worsening shock, recurrent ventricular arrhythmias, or signs that the patient may need more urgent cardiac intervention. The final major priority is protecting the brain from secondary injury. Luria emphasizes normothermia, avoiding fever, maintaining perfusion, avoiding both hypoxia and hyperoxia, and targeting normal or high-normal CO2 rather than rapidly overcorrecting ventilation. Sedation should be minimized when possible so the receiving team can obtain a meaningful neurologic exam, while still treating pain, agitation, ventilator asynchrony, or unsafe movement. The episode closes with the “ALIVE-12” checklist: Airway secure, Look at the heart, Inotrope/pressor support, Ventilate safely, End-tidal CO2 monitoring, and a 12-lead ECG after enough time has passed for better diagnostic accuracy. **Key Points** - Post-cardiac arrest transport can be organized around four priorities: help the heart, hunt for the cause, sustain the brain, and provide good supportive critical care. - A MAP around 65 is generally an appropriate perfusion goal; higher blood pressure targets have not clearly shown benefit. - Norepinephrine is a reasonable first-line pressor, with epinephrine added when inotropic support is needed. - Repeat 12-lead EKGs matter; an ECG immediately after ROSC may be misleading, so repeating around 8–10 minutes and again later can improve diagnostic accuracy. - Brain protection means avoiding hypotension, fever, hypoxia, hyperoxia, and hypocapnia while minimizing unnecessary sedation.