ICU · Post-cardiac arrest care
Post-Cardiac Arrest Care and Targeted Temperature Management
Also known as Post-arrest care · Post-cardiac arrest syndrome · Targeted temperature management · TTM2 · TTM trial · HACA · HYPERION · Eurotherm3235 · CoolCap · TOBY · Prognostication · Neuroprotection · COACT · Shivering management · Cooling technique · Neonatal HIE
Post-cardiac-arrest care and targeted temperature management: post-arrest syndrome pillars, HACA/TTM/TTM2/HYPERION trial arc with fever avoidance as the active ingredient, ERC guidance (32-36C for 24h, avoid fever above 37.7C for 72h), COACT angiography timing, hyperoxia and glucose targets, BSAS shivering ladder, slow rewarming, neonatal cooling exception, and multimodal prognostication at 72 hours.
Checked against its sources on 13 Oct 2026
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Red flags
- TTM2: hypothermia not superior to normothermia (50 vs 48 percent mortality) — fever avoidance is the active ingredient
- Avoid fever above 37.7C for at least 72 hours after ROSC while comatose
- Prognosticate multimodally at 72 hours or later, confounders excluded — no single modality suffices
- COACT: no benefit of immediate over delayed angiography without ST elevation
Meet the patient
A man in his fifties is wheeled into your ICU at 3am, intubated and comatose, after an out-of-hospital VF arrest with early bystander CPR, shocks and adrenaline to ROSC. The cath lab has just opened his occluded LAD. Core temperature near normothermia, blood pressure supported on noradrenaline, lactate raised. He has not moved to command.[2]
The arrest is survived; the brain is still at risk. The three questions that decide his next three days are the three that decide every post-arrest patient: what temperature do I hold, when do I rewarm, and when — only when — do I prognosticate? Hold those three and the whole protocol slots into place.[2]
References21ShowHide
- [1]Nolan JP, Neumar RW, Adrie C, et al. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A scientific statement from the International Liaison Committee on Resuscitation Resuscitation, 2008.PMID 18963350
- [2]Nolan JP, Sandroni C, Böttiger BW, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care Intensive Care Med, 2021.PMID 33765189
- [3]Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med, 2002.PMID 11856793
- [4]Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia N Engl J Med, 2002.PMID 11856794
- [5]Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest N Engl J Med, 2013.PMID 24237006
- [6]Dankiewicz J, Cronberg T, Lilja G, et al. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest N Engl J Med, 2021.PMID 34133859
- [7]Lascarrou JB, Merdji H, Le Gouge A, et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm N Engl J Med, 2019.PMID 31577396
- [8]Lemkes JS, Janssens GN, van den Hoeven NW, et al. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation N Engl J Med, 2019.PMID 30883057
- [9]Kilgannon JH, Jones AE, Shapiro NI, et al. Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality JAMA, 2010.PMID 20516417
- [10]Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients N Engl J Med, 2009.PMID 19318384
- [11]Sandroni C, Cariou A, Cavallaro F, et al. Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine Resuscitation, 2014.PMID 25438253
- [12]Andrews PJD, Sinclair HL, Rodriguez A, et al. Hypothermia for Intracranial Hypertension after Traumatic Brain Injury N Engl J Med, 2015.PMID 26444221
- [13]Gluckman PD, Wyatt JS, Azzopardi DV, et al. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy Lancet, 2005.PMID 15721471
- [14]Azzopardi DV, Strohm B, Edwards AD, et al. Moderate hypothermia to treat perinatal asphyxial encephalopathy N Engl J Med, 2009.PMID 19797281
- [15]Shankaran S, Laptook AR, Ehrenkranz RA, et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy N Engl J Med, 2005.PMID 16221780
- [16]Shankaran S, Pappas A, McDonald SA, et al. Childhood outcomes after hypothermia for neonatal encephalopathy N Engl J Med, 2012.PMID 22646631
- [17]Badjatia N, Strongilis E, Gordon E, et al. Metabolic impact of shivering during therapeutic temperature modulation: the Bedside Shivering Assessment Scale Stroke, 2008.PMID 18927450
- [18]Weant KA, Martin JE, Humphries RL, et al. Pharmacologic options for reducing the shivering response to therapeutic hypothermia Pharmacotherapy, 2010.PMID 20653360
- [19]Sessler DI Thermoregulatory defense mechanisms Crit Care Med, 2009.PMID 19535948
- [20]Polderman KH Application of therapeutic hypothermia in the ICU: opportunities and pitfalls of a promising treatment modality. Part 1: indications and evidence Intensive Care Med, 2004.PMID 14767591
- [21]Polderman KH Application of therapeutic hypothermia in the ICU: opportunities and pitfalls of a promising treatment modality. Part 2: practical aspects and side effects Intensive Care Med, 2004.PMID 14767590