If hypotension persists after a 1- to 2-L IV isotonic crystalloid bolus following ROSC, what is an appropriate next step?

• A. Start an IV vasopressor infusion with epinephrine (2-10 mcg/min)
• B. Initiate a vasopressor infusion with an agent such as norepinephrine
• C. Administer an additional crystalloid bolus
• D. Administer a sedative

Answer: (B)

After ROSC, persistent hypotension usually means shock from vasodilation and reduced vascular tone, so the goal is to restore perfusion pressure with a vasopressor. Starting a norepinephrine infusion is the best next step because it primarily increases systemic vascular resistance to raise mean arterial pressure, helping improve coronary and cerebral perfusion with less risk of raising heart rate or oxygen demand compared with other agents. The aim is to achieve a MAP around 65 mmHg to support organ perfusion.

Adding more IV fluids at this point can worsen edema and pulmonary congestion without addressing the underlying vasodilation. A sedative would further depress blood pressure and is not appropriate in this situation. An epinephrine vasopressor could be considered, but norepinephrine is preferred due to a more favorable balance of effects on pressure and heart rate.