Table of Contents:
- What is ROSC?
- What Are The Major Signs of ROSC?
- The Lazarus Phenomenon: A Rare Form of Delayed ROSC
- How to Maximize ROSC Success?
- Post Cardiac Arrest Care Algorithm
- Spot ROSC Early and Take the Right Steps to Save a Life!
Consider a scenario where someone collapses suddenly. No pulse. No breathing. It’s a race against time. A bystander starts CPR while someone else calls 911. Paramedics arrive, deliver a shock with a defibrillator, and then, finally, a pulse returns. But does that mean the person is out of danger? Not quite.
This moment is called ROSC, Return of Spontaneous Circulation. Now, you must be thinking, what is ROSC?. It is the state when the heart starts pumping blood again after a cardiac arrest. But the journey isn’t over yet. After ROSC, the body needs time and medical support to recover fully. The reality is that only about 10% of people survive an out-of-hospital cardiac arrest. Without proper post-cardiac arrest care, complications like brain damage, heart failure, or even another cardiac arrest can follow.
So, what are the signs of ROSC? What kind of care is needed after the heart starts beating again? Keep reading to find out.
What is ROSC?
Return of Spontaneous Circulation (ROSC) occurs when the heart starts pumping blood again after it has stopped due to cardiac arrest. This is the basic ROSC definition. This happens when emergency treatments, such as Cardiopulmonary Resuscitation (CPR) and advanced cardiac life support (ACLS), restore blood flow and oxygen delivery to vital organs. ROSC is a crucial step in saving a person’s life, but it does not mean full recovery. The patient remains in a fragile state and requires continuous medical monitoring and supportive care.
Now that we know what the ROSC medical abbreviation is, let us see the signs of ROSC.
Read More: Acls discount code
What Are The Major Signs of ROSC?
Signs of ROSC show that the heart and body are starting to recover after cardiac arrest. This means that blood is flowing again, and the brain and organs are getting oxygen. Doctors and medical teams look for signs to check if a patient is improving.
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Detectable Pulse
A palpable pulse is the most important sign of ROSC. It means the heart has resumed pumping blood. Healthcare providers check the carotid (neck) or femoral (groin) artery for a pulse. The pulse may start off as weak or irregular and hence, you should continuously monitor the patient and provide supportive care.
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Rise in Blood Pressure
After ROSC, systolic blood pressure (SBP) may increase from the normal range of 120 mmHg. This indicates improved cardiac output. However, it can be unstable due to myocardial dysfunction (the heart muscle isn’t working properly) or hypovolemia (there isn’t enough blood in the body). IV fluids and vasopressor medications, such as epinephrine or norepinephrine, are often necessary. These help stabilize blood pressure and prevent organ failure.
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Spontaneous Breathing
Some patients begin spontaneous respiration, a sign that the brainstem is functioning. This may include gasping (agonal breathing) or irregular breaths. If breathing remains weak, mechanical ventilation may be required to ensure proper oxygenation and reduce the risk of hypoxic brain injury. Even if spontaneous breathing occurs, oxygen levels should still be closely monitored to prevent complications.
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Improved Skin Color
A person in cardiac arrest often has cyanosis (bluish or grayish skin) due to poor oxygenation, which is most noticeable on the lips, fingertips, and mucous membranes. After ROSC, improved peripheral perfusion restores a pinkish skin tone, indicating better oxygen delivery. However, persistent pallor or mottling may suggest inadequate circulation requiring further intervention.
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Pupil Reaction
After ROSC, the pupillary light reflex may return, indicating brainstem activity. Fixed or dilated pupils suggest severe hypoxic-ischemic brain injury. Neurological exams, EEG, and imaging (CT or MRI) help assess brain recovery. Close monitoring ensures timely interventions for improving neurological outcomes. A returning pupillary light reflex indicates brainstem activity and ROSC recovery.
The Lazarus Phenomenon: A Rare Form of Delayed ROSC
The Lazarus Phenomenon is a rare medical event where a patient’s heart spontaneously starts beating again after CPR has been stopped. This delayed return of spontaneous circulation typically occurs within 5-10 minutes after resuscitation efforts end. While it may seem like a miraculous recovery, most patients who experience this phenomenon still face severe health complications. Some of the major causes of delayed ROSC are:
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Intrinsic Positive End-Expiratory Pressure (auto-PEEP)
This happens when air gets trapped in the lungs because a person isn’t fully exhaling before taking another breath. During CPR, positive pressure ventilation can cause air to build up in the lungs, preventing blood from returning to the heart. When CPR stops, this trapped air is released, allowing normal circulation to resume.
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Delayed Drug Effects
Medications like epinephrine and vasopressors, which help restore circulation, may take time to work. As these drugs continue acting in the bloodstream, they might help restart the heart after CPR has ceased.
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Misinterpretation Of Patient’s Condition
Weak heart activity or agonal gasps may be mistaken for a lack of response, leading to premature cessation of resuscitation. Point-of-care ultrasound (POCUS) and other tools can help reduce misinterpretation and improve decision-making during resuscitation efforts.
Is the Lazarus Phenomenon a Sign of Survival?
Not necessarily. While the return of spontaneous circulation is a positive sign, many patients still suffer from brain damage, organ failure, or severe cardiac dysfunction due to prolonged oxygen deprivation. Continuous neurological monitoring, hemodynamic support, and intensive care are crucial in determining whether the patient can recover and regain cognitive and motor function.
How to Maximize ROSC Success?
When someone’s heart stops, immediate intervention is needed for survival. A study published in the National Library of Medicine shows that ROSC occurs in about 30-50% of cardiac arrest cases, but survival to hospital discharge remains much lower, around 10-20%. Steps to improve the chances of ROSC success are:
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Early Recognition of Cardiac Arrest
Recognizing cardiac arrest quickly improves ROSC success rates, which is around 8.3%. Check if the person is unresponsive and not breathing normally or only gasping. Assess for a pulse in the carotid artery within 10 seconds. If there is no pulse, begin high-quality CPR immediately to restore blood flow to the brain and heart.
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High-Quality CPR
Perform chest compressions at a depth of at least 2 inches and a rate of 100-120 compressions per minute. Allow the chest to recoil after each compression fully. Avoid interruptions, as stopping CPR reduces survival chances. Combine compressions with rescue breaths for proper oxygenation, ensuring continuous blood circulation.
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Effective Defibrillation
For shockable rhythms like ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT), use an Automated External Defibrillator (AED) immediately. Deliver a shock as soon as possible and resume CPR immediately after. Defibrillation restores a normal heart rhythm by stopping abnormal electrical activity in the heart.
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Proper Airway Management
Open the airway using the head-tilt, chin-lift maneuver. Provide oxygen using a bag-mask device or insert an advanced airway (endotracheal tube or supraglottic device) if needed. Adequate ventilation prevents brain injury and supports circulation, ensuring enough oxygen reaches vital organs. Open airways and oxygenation help maintain medical ROSC.
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Medication Administration
Give epinephrine within the first 3-5 minutes of CPR to increase blood pressure and heart activity. If the heart rhythm remains unstable, use antiarrhythmic drugs like amiodarone or lidocaine. These medications help control abnormal heart rhythms and improve the chances of restoring a stable heartbeat.
Post-cardiac arrest Care Algorithm
When a person regains a heartbeat after cardiac arrest (Return of Spontaneous Circulation or ROSC), the next challenge is keeping them stable and preventing further damage. The body is still in a fragile state, and without proper care, serious complications can occur.
Doctors follow a step-by-step plan, called the post-cardiac arrest care algorithm, to give the patient the best chance of recovery. This includes:
Optimize Ventilation and Oxygenation
After ROSC, proper ventilation and oxygenation are essential to prevent brain and organ damage. Oxygen saturation should be maintained between 94%-98% to ensure adequate oxygen delivery while avoiding hyperoxia. Mechanical ventilation may be needed if breathing is weak. Hyperventilation must be avoided, as it reduces brain blood flow and worsens injury.
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Control Blood Pressure
Systolic blood pressure should stay above 90 mmHg to ensure organ perfusion. IV fluids are given first, and vasopressors like epinephrine or norepinephrine may be used if needed to stabilize circulation and prevent further brain and heart damage.
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Identify and Treat Cardiac Issues
A 12-lead ECG checks for heart attack, arrhythmias, or conduction defects. If a heart attack is suspected, coronary angiography helps remove blockages. Cardiac biomarkers like troponin guide treatment and assess heart muscle damage after cardiac arrest.
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Targeted Temperature Management (TTM)
Therapeutic hypothermia or Targeted Temperature Management (TTM) should be done to cool the body to 32-36°C (89.6-96.8°F). It helps in reducing brain injury and inflammation. Methods include cooling blankets, ice packs, or cold IV fluids. After 24-48 hours, gradual rewarming prevents complications like electrolyte imbalances or dangerous heart rhythms.
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Neurological Monitoring
Doctors check pupil response, EEG for seizures, and brain imaging (CT/MRI) to assess injury. Hypoxic-ischemic encephalopathy and cerebral swelling impact prognosis. Close monitoring guides treatment decisions and helps determine the likelihood of brain function recovery.
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Long-Term Care
Patients may need rehabilitation, including speech, physical, and cognitive therapy. Cardiac rehabilitation focuses on lifestyle changes, medications, and monitored exercise to prevent future cardiac events and improve overall health after surviving cardiac arrest.
Read More: ACLS Guidelines 2020 to 2025
Spot ROSC Early and Take the Right Steps to Save a Life!
ROSC is a huge step in saving a life after cardiac arrest, but it is just the beginning. Even after the heart starts beating again, there might be complications like brain damage, heart issues, and organ failure that remain. After learning what ROSC is, you should also know why post-cardiac arrest care is so important. Treatments like targeted temperature management, blood pressure control, and neurological monitoring can help in recovering faster.
Want to be prepared? Advanced Cardiac Life Support (ACLS) training will teach you what ROSC is and also train you to provide expert care. Don’t wait, and start your learning journey today!
References:
https://www.aclsonline.us/blog/rosc/
https://emedicine.medscape.com/article/2172100-overview?form=fpf
