CME 23/01/14 Therapeutic Hypothermia – current evidence

Here is Bethan’s summary on the current evidence and ARC standpoint on post cardiac arrest therapeutic hypothermia post release of the most recent trial data:

  • Nielsen N et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med Nov 17 2013 doi: 10.1056/NEJMoa1310519

Inclusion and exclusion criteria from the TTM study:
Inclusion criteria:
1. Age ≥18 years.
2. Out of hospital cardiac arrest of presumed cardiac cause.
3. Sustained return of spontaneous circulation (ROSC)#.
4. Unconsciousness (GCS <8) (patients not able to obey verbal commands) after sustained
#Sustained ROSC: Sustained ROSC is when chest compressions have been not required for 20
consecutive minutes and signs of circulation persist
Exclusion criteria:
1. Obvious or suspected pregnancy
2. Known bleeding diathesis (medically induced coagulopathy (e.g. warfarin, clopidogrel)
does not exclude the patient).
3. Suspected or confirmed acute intracranial bleeding
4. Suspected or confirmed acute stroke
5. Unwitnessed cardiac arrest with initial rhythm asystole
6. Known limitations in therapy and Do Not Resuscitate-order
7. Known disease making 180 days survival unlikely
8. Known pre-arrest Cerebral Performance Category 3 or 4
9. >4 hours (240 minutes) from ROSC to screening
10. Systolic blood pressure <80 mm Hg in spite of fluid loading/vasopressor and/or inotropic
medication/intra aortic balloon pump#
11. Temperature on admission <30°C.

# If the systolic blood pressure (SBP) was recovering during the inclusion window (220 minutes) the patient could be included. The standard
definition of shock did not preclude inclusion: A systolic blood pressure<90mmHg for >30min or end-organ hypoperfusion (cool
extremities, urine output<30ml/hour, heart rate <60 beats/min).
  Here is the most recent statement from the ARC (Decmeber 2013)   Here is Chris Nickson’s take on the evidence and resulting discussions, titled “Reports of therapeutic hypothermia’s death are greatly exaggerated” from LITFL   Here is an example Targeted Temperature Managment Protocol & Post-ROSC Care Package from Mount Sinai Hospital

Dr James Wheeler
Dr James Wheeler

Emergency Physician, SCGH, WA, Australia

Articles: 500

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