Post-cardiac Arrest Care After ROSC Practice Questions

25 multiple-choice questions on Post-cardiac arrest care after ROSC for paramedic and EMT students, from Chapter 40 (Responding to the Field Code). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Before sedating a patient after ROSC, which finding is most useful to record and pass on for the hospital's neurologic assessment?

   1. A. The time of the last epinephrine dose
   2. B. The skin color and capillary refill time
   3. C. The total number of shocks delivered
   4. D. Best motor response and pupil reactivity
   Show answer

   Answer: D. Best motor response and pupil reactivity

   The best motor response (part of the GCS) and pupillary reflexes before sedation give the hospital an early baseline, and both are components of the multimodal neurologic assessment that guides care and later prognostication. Sedation and paralysis will hide them, so they must be documented first. Drug timing, shock count, and skin perfusion are important to report, but they describe the resuscitation and circulation, not brain function. (2025 AHA Part 11 post-arrest care.)

2. After ROSC, an intubated man is being bagged at 10 per minute, and his ETCO2 rises to 58 mmHg. His BP is stable. You should:

   1. A. Keep 10/min, since CO2 protects the brain
   2. B. Bag at 30/min to bring it under 25
   3. C. Raise the rate slightly and recheck
   4. D. Give sodium bicarbonate for the CO2
   Show answer

   Answer: C. Raise the rate slightly and recheck

   The goal after ROSC is normocapnia (PaCO2 or ETCO2 of about 35 to 45 mmHg), so a modest increase in rate, for example to 12 to 14 per minute, with reassessment, corrects hypercapnia. High CO2 dilates cerebral vessels and can raise intracranial pressure, so it is not protective. Bagging at 30 overshoots into hypocapnia, which constricts cerebral vessels and worsens brain ischemia. Bicarbonate generates more CO2 and does not treat hypoventilation. (2025 AHA Part 11.)

3. Ten minutes after ROSC, your partner is bagging an intubated 61-year-old man at 30 breaths per minute, and the ETCO2 is 22 mmHg. You should:

   1. A. Keep the rate at 30 to lower the ETCO2
   2. B. Slow the rate to about 10 per minute
   3. C. Raise the rate to 40 to reach 30 mmHg
   4. D. Stop bagging and let him breathe alone
   Show answer

   Answer: B. Slow the rate to about 10 per minute

   An ETCO2 of 22 mmHg after ROSC usually reflects hyperventilation, which constricts cerebral vessels and lowers cardiac output. Starting at about 10 breaths per minute and adjusting to an ETCO2 of 35 to 45 mmHg avoids this.

4. Fifteen minutes after ROSC, the monitor shows a BP of 92/42 mmHg with a displayed MAP of 59 mmHg. Regarding blood pressure support, you should:

   1. A. Treat it, since the MAP is under 65
   2. B. Do nothing, since the SBP is over 90
   3. C. Wait until the SBP falls under 80
   4. D. Treat only if crackles are also heard
   Show answer

   Answer: A. Treat it, since the MAP is under 65

   Post-arrest guidance aims to avoid hypotension by keeping the SBP at least 90 mmHg and the MAP at least 65 mmHg; a MAP of 59 means organ perfusion pressure is low even though the systolic number looks acceptable, so fluids and a vasopressor are titrated to the MAP. Relying on the SBP alone misses low diastolic and mean pressures, which are common after epinephrine and with vasodilation. Waiting for the SBP to fall under 80 lets hypotension linked to worse survival continue. Crackles affect the choice between fluid and pressor, not whether to treat. (2025 AHA Part 11.)

5. After ROSC, a 70-year-old woman has a BP of 78/48 mmHg, crackles in both lungs, and an SpO2 of 90% on 100% oxygen. The best initial treatment is:

   1. A. A 2-liter normal saline bolus
   2. B. Nitroglycerin 0.4 mg sublingual
   3. C. Epinephrine 1 mg by IV push
   4. D. A titrated vasopressor infusion
   Show answer

   Answer: D. A titrated vasopressor infusion

   Post-arrest hypotension with pulmonary edema suggests myocardial stunning (cardiogenic shock), so a titrated vasopressor such as norepinephrine or an epinephrine infusion is started to reach an SBP of at least 90 and a MAP of at least 65 mmHg, with fluids given only cautiously. A 2-liter bolus would worsen the pulmonary edema and hypoxemia. Nitroglycerin lowers BP further and is contraindicated in hypotension. A 1-mg IV push is an arrest dose and can cause severe hypertension and dysrhythmias in a patient with a pulse. (2025 AHA Part 11.)

6. A 12-lead ECG obtained 2 minutes after ROSC shows ST changes. Because very early post-ROSC ECGs often show changes that later resolve, it is best to:

   1. A. Repeat it at once, within 1 minute
   2. B. Repeat it after arrival at the ED
   3. C. Repeat it after about 8 to 10 minutes
   4. D. Discard it and rely on troponin at the ED
   Show answer

   Answer: C. Repeat it after about 8 to 10 minutes

   ECGs obtained in the first few minutes after ROSC have a high false-positive rate for STEMI because of the arrest, shocks, and catecholamines. A repeat ECG after about 8 to 10 minutes is more accurate for cath lab decisions, while a clear STEMI should still be acted on. Repeating it within a minute is still inside the early window of false positives, waiting until hospital arrival delays a possible cath lab activation, and a troponin result cannot replace the ECG for STEMI decisions.

7. During a 40-minute transport after ROSC, a comatose patient's temperature rises to 38.4°C (101.1°F). You should:

   1. A. Add blankets to prevent him from shivering
   2. B. Run 2 L of cold saline in as fast as possible
   3. C. Leave it until hospital arrival
   4. D. Remove extra covers and cool per protocol
   Show answer

   Answer: D. Remove extra covers and cool per protocol

   Fever after cardiac arrest is linked to worse brain outcomes, and AHA recommends actively preventing it in patients who do not follow commands, so remove excess covers and use the cooling measures in your protocol, such as ice packs. Adding blankets raises the temperature further. Rapid infusion of large volumes of cold saline in the field increased re-arrest and pulmonary edema in trials and is not recommended. Ignoring a fever for 40 minutes lets a treatable injury continue. (2025 AHA Part 11; Kim 2014; TTM2 2021.)

8. Current AHA guidance on temperature control after ROSC in a patient who does not follow commands is to:

   1. A. Keep 32°C to 37.5°C and prevent fever
   2. B. Keep 36°C to 39°C, allow mild fever
   3. C. Cool to 33°C for 12 hours, then rewarm
   4. D. Cool to 30°C (86°F) as fast as possible
   Show answer

   Answer: A. Keep 32°C to 37.5°C and prevent fever

   The 2025 AHA guidelines recommend deliberate temperature control at a constant temperature between 32°C and 37.5°C (89.6°F to 99.5°F) for patients who do not follow commands after ROSC, maintained for at least 36 hours, with active prevention of fever; after TTM2, fever avoidance rather than deep cooling is the main goal. (European ERC-ESICM guidance adds fever prevention for at least 72 hours.) A range that reaches 39°C allows the fever linked to worse brain outcomes. Twelve hours is far shorter than the 36-hour minimum, and fever prevention should continue after cooling. Cooling to 30°C goes below the 32°C floor and adds dysrhythmia and bleeding risk. (2025 AHA Part 11; TTM2 2021.)

9. Your service is considering rapid infusion of cold IV saline in the field after ROSC. Current evidence shows this practice:

   1. A. Improves neurologic outcomes in most adults
   2. B. Is required for comatose ROSC patients
   3. C. Is discouraged; it raises re-arrest risk
   4. D. Is recommended for in-hospital arrest
   Show answer

   Answer: C. Is discouraged; it raises re-arrest risk

   Randomized trials found that prehospital cold saline increased re-arrest and pulmonary edema without improving survival, so AHA recommends against routine prehospital cooling with rapid cold IV fluid. Temperature control is started at the hospital.

10. Fifteen minutes after ROSC, a 59-year-old man has generalized tonic-clonic seizure activity. You should:

    1. A. Give phenytoin ahead of a benzodiazepine
    2. B. Give a benzodiazepine per protocol
    3. C. Give no drug; seizures are expected
    4. D. Paralyze him to stop the movements
    Show answer

    Answer: B. Give a benzodiazepine per protocol

    Seizures are common after ROSC and increase cerebral oxygen demand, so they should be treated, typically with a benzodiazepine. Seizures are not a benign or expected finding to be left alone. A second-line drug such as phenytoin follows rather than replaces the benzodiazepine, and a paralytic only hides the movements while the brain keeps seizing.

11. After ROSC, defibrillation pads should be:

    1. A. Removed to prevent skin burns
    2. B. Moved to the AP position at once
    3. C. Removed once a 12-lead is done
    4. D. Kept on in case of re-arrest
    Show answer

    Answer: D. Kept on in case of re-arrest

    Re-arrest is common in the first minutes and hours after ROSC, so the pads should stay on and connected for immediate defibrillation. Removing them adds delay if VF recurs.

12. Oxygen is titrated after ROSC rather than kept at 100% because:

    1. A. Hyperoxia may worsen reperfusion injury
    2. B. Oxygen causes the coronary arteries to dilate
    3. C. High oxygen levels trigger recurrent VF
    4. D. Pulse oximetry is unreliable after ROSC
    Show answer

    Answer: A. Hyperoxia may worsen reperfusion injury

    Excess oxygen generates free radicals that may increase brain and myocardial injury after reperfusion, so oxygen is titrated once the SpO2 can be measured reliably. Oxygen does not dilate coronaries; high levels cause modest vasoconstriction.

13. Hyperventilation after ROSC is harmful to the brain mainly because hypocapnia causes:

    1. A. Cerebral vasodilation
    2. B. Cerebral vasoconstriction
    3. C. Metabolic acidosis
    4. D. Increased cerebral blood flow
    Show answer

    Answer: B. Cerebral vasoconstriction

    Low CO2 constricts cerebral arterioles and reduces cerebral blood flow at a time when the brain is already injured. Hypercapnia, not hypocapnia, causes cerebral vasodilation.

14. Among patients admitted after ROSC from out-of-hospital cardiac arrest who later die, the most common cause of death is:

    1. A. Rib fractures from CPR
    2. B. Aspiration pneumonia
    3. C. Anoxic brain injury
    4. D. Recurrent VF
    Show answer

    Answer: C. Anoxic brain injury

    Hypoxic-ischemic brain injury accounts for about two-thirds of deaths after admission for out-of-hospital arrest, often through withdrawal of care for poor neurologic prognosis. This is why post-ROSC care focuses on oxygenation, ventilation, perfusion, and temperature.

15. After ROSC, an intubated 50-year-old man begins biting the tube and fighting ventilations. His BP is 128/76 mmHg. You should:

    1. A. Restrain his hands and keep bagging
    2. B. Give sedation and analgesia per protocol
    3. C. Give a paralytic alone, without sedation
    4. D. Bag faster to override his breathing
    Show answer

    Answer: B. Give sedation and analgesia per protocol

    Agitation and tube intolerance after ROSC are common; sedation and analgesia, given with attention to blood pressure, protect the airway and reduce oxygen demand. Paralysis without sedation leaves an aware patient unable to move. Restraints alone do not stop him biting the tube or fighting the ventilator, and bagging faster against his efforts adds hyperventilation and dyssynchrony.

16. After ROSC, a comatose patient has had no seizure activity. Giving an antiseizure drug now to prevent seizures is:

    1. A. Recommended for every comatose patient
    2. B. Required before transport can begin
    3. C. Recommended only after a VF arrest
    4. D. Not recommended
    Show answer

    Answer: D. Not recommended

    AHA recommends treating clinical seizures after cardiac arrest (as in 07#10) but does not recommend seizure prophylaxis, because preventive drugs did not improve outcomes in two randomized trials (Class 3: No Benefit). Being comatose is not an indication by itself. Transport does not depend on prophylaxis. The initial rhythm does not create an indication. (AHA 2020 Part 3 and 2025 Part 11 post-arrest care.)

17. Fixed, dilated pupils in the first minutes after ROSC:

    1. A. Confirm that brain death has occurred
    2. B. Mean resuscitation should be withdrawn
    3. C. Do not reliably predict a poor outcome
    4. D. Prove that a stroke caused the arrest
    Show answer

    Answer: C. Do not reliably predict a poor outcome

    Pupil findings soon after ROSC are affected by epinephrine, hypoxia, and drugs and do not predict neurologic outcome; formal prognostication is done in the hospital, usually at least 72 hours after rewarming. Field findings should never be used to withdraw care.

18. During transport after ROSC, your patient's pulse disappears and the monitor shows VF. You should:

    1. A. Resume CPR and defibrillate
    2. B. Give amiodarone 300 mg first
    3. C. Increase the vasopressor dose
    4. D. Divert to the closest hospital
    Show answer

    Answer: A. Resume CPR and defibrillate

    Re-arrest is treated with the standard arrest algorithm, starting with CPR and a shock for VF. Changing a drip or giving a drug before a shock delays the most effective treatment.

19. A post-ROSC 12-lead in a patient whose arrest began in VF shows no ST elevation. Which statement is correct?

    1. A. A coronary cause has been ruled out
    2. B. No further 12-leads will be needed
    3. C. Emergency angiography is now harmful
    4. D. A coronary cause is still possible
    Show answer

    Answer: D. A coronary cause is still possible

    Many VF arrest patients have acute coronary occlusion without classic STEMI, so they still benefit from a cardiac arrest center, and emergency angiography may be reasonable for selected patients. A single non-diagnostic ECG does not exclude ischemia, and serial 12-leads are useful.

20. A 46-year-old man has a witnessed VF arrest that remains refractory after three shocks. You are 12 minutes from a center that offers ECMO. Many protocols would favor:

    1. A. Termination after the fourth failed shock
    2. B. Early transport on mechanical CPR
    3. C. Staying on scene for 60 minutes of ALS
    4. D. Transport only after ROSC is achieved
    Show answer

    Answer: B. Early transport on mechanical CPR

    ECPR may be reasonable for selected younger patients with witnessed refractory VF, but it must start within roughly 60 minutes of collapse, so early transport with mechanical CPR is key. Eligibility criteria vary by system.

21. Twenty minutes after ROSC, a 60-year-old man's blood glucose is 48 mg/dL. You should:

    1. A. Give IV dextrose
    2. B. Give oral glucose gel
    3. C. Give insulin 10 units IV
    4. D. Recheck it in 30 minutes
    Show answer

    Answer: A. Give IV dextrose

    Hypoglycemia worsens brain injury and must be corrected in the post-arrest patient. An unresponsive, intubated patient cannot safely take oral glucose.

22. A 66-year-old woman has ROSC with an i-gel in place, good chest rise, and a normal capnography waveform. Regarding the airway, you should:

    1. A. Swap it for an ETT before moving her
    2. B. Remove it and switch to a BVM
    3. C. Keep the i-gel while it is working
    4. D. Replace it with a larger i-gel
    Show answer

    Answer: C. Keep the i-gel while it is working

    An SGA that is ventilating well does not need to be exchanged in the field; a tube exchange carries risks of desaturation and failed intubation. Some protocols call for exchange if ventilation is inadequate or before long transports.

23. During transport after ROSC, a 64-year-old man's ETCO2 falls from 38 to 18 mmHg with no change in ventilation. You should first:

    1. A. Increase the ventilation rate to compensate
    2. B. Check his pulse and blood pressure
    3. C. Give a dose of sodium bicarbonate
    4. D. Deflate and reinflate the ET cuff
    Show answer

    Answer: B. Check his pulse and blood pressure

    With constant ventilation, a sudden fall in ETCO2 reflects falling cardiac output, which may signal hypotension or impending re-arrest, so check the pulse and BP first. Increasing the ventilation rate lowers ETCO2 further and hides the problem. Bicarbonate does not treat low output and briefly raises ETCO2, confusing the picture. A cuff problem would cause a leak or a lost waveform, not a smooth fall with an unchanged waveform. (2025 AHA Part 11.)

24. The components of post-cardiac arrest syndrome include brain injury, systemic ischemia-reperfusion response, the persisting cause of the arrest, and:

    1. A. Primary adrenal failure
    2. B. Cerebral vasospasm
    3. C. Myocardial dysfunction
    4. D. Pulmonary hypertension
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    Answer: C. Myocardial dysfunction

    Post-arrest myocardial stunning causes low cardiac output and hypotension that often improves over 24 to 72 hours, which is why vasopressors are commonly needed after ROSC. Adrenal insufficiency can occur, but it is not one of the four defined components. Cerebral vasospasm and pulmonary hypertension are not components either; the brain component is hypoxic-ischemic injury rather than vessel spasm.

25. After ROSC, the patient opens his eyes and follows simple commands. Compared with a comatose patient, he:

    1. A. Can be released from EMS care on scene
    2. B. Needs no further 12-lead ECGs
    3. C. No longer needs any monitoring
    4. D. Still needs full post-arrest care
    Show answer

    Answer: D. Still needs full post-arrest care

    Even awake survivors can re-arrest and often have the cause of arrest, such as coronary occlusion, still present, so they need monitoring, a 12-lead, and transport to an appropriate center. Temperature control is aimed at patients who do not follow commands.