Patient handout

Post-cardiac-arrest care — hypothermic cardiac arrest

PRODUCTION

1. Your condition

This handout is for post-cardiac-arrest care — hypothermic cardiac arrest. Your care team identified this based on: rosc after hypothermic cardiac arrest — environmental, immersion, drug-induced, or endocrine etiology.

Other reasons your team may use this plan: severe accidental hypothermia (core <28 °c) with cardiac arrest — ecmo/cpb candidate per elso consensus; comatose post-rewarming hypothermic arrest survivor — ttm candidate; neuroprog interpreted with caution given hypothermia confounding (sandroni 2021 pmid 33745427).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
norepinephrine	0.05-0.5 µg/kg/min titrate MAP ≥65	IV	continuous	SOAP-II PMID 20200382; first-line post-ROSC vasoactive; particularly important during rewarming-related vasoplegia phase
amiodarone	300 mg IV bolus → 150 mg if recurrent → 1 mg/min × 6h → 0.5 mg/min × 18h; HOLD additional doses if core <30 °C	IV	modified for hypothermia	AHA 2020 ACLS Class IIb; in hypothermia limit to 1 dose until warmed >30 °C, then resume standard cadence
epinephrine	1 mg IV q3-5 min if normothermic; if core <30 °C → withhold further doses; if 30-34 °C → space q6-10 min	IV	modified for hypothermia	AHA 2020 ACLS — modified dosing intervals for hypothermia given reduced metabolism + receptor responsiveness
magnesium sulfate	1-2 g IV	IV	one-time + repeat for TdP	AHA 2020 ACLS Class IIa for TdP; correct hypomagnesemia first
levothyroxine	200-500 µg IV loading → 50-100 µg IV daily	IV	daily	AACE myxedema coma management — IV levothyroxine + stress-dose steroids; precede T4 with hydrocortisone if adrenal insufficiency possible
hydrocortisone	100 mg IV q8h × 24-48h	IV	q8h	Standard adrenal crisis + myxedema coma management; precede levothyroxine with steroids to avoid precipitating crisis
propofol	5-50 µg/kg/min	IV	continuous; titrate RASS	PADIS 2018; hepatic metabolism slowed in hypothermia → reduce dose during cooling phase
fentanyl	25-200 µg/h	IV	continuous	PADIS 2018; analgesia + shivering suppression for TTM
tranexamic acid	1 g IV over 10 min	IV	within 3h of bleeding onset	CRASH-2 PMID 20554319 if traumatic bleeding co-existing with hypothermic arrest

Plan: Hypothermic post-arrest phenotype — modified ACLS (drug spacing + defib limitation), ECMO/CPB rewarming gold standard for severe + arrest, etiology-specific endocrine therapy, post-rewarming bundle (AHA 2020 hypothermia + ERC 2021 + ELSO accidental hypothermia + Walpoth 1997)

3. When to call your provider

Contact your care team if any of the following happen:

ICD therapy delivered → urgent EP; consider catheter ablation per VANISH (PMID 27149033) if structural substrate
EF declining despite the four foundational heart-failure medications → advanced HF eval
Substance-use relapse with safety risk → urgent intervention

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Core temperature <28 °C with cardiac arrest — ECMO/CPB rewarming is gold standard (Walpoth 1997 PMID 9395428; ELSO accidental hypothermia consensus); favourable outcomes documented at very low core temperatures(life-threatening)
Recurrent VF or arrhythmia at core temp <30 °C — drugs less effective, defibrillation limited; bridge with ECMO rewarming(life-threatening)
Persistent severe metabolic acidosis (pH <7.2 + lactate >6) post-rewarming despite resuscitation — indicates inadequate perfusion or rewarming-related complication
Profound vasoplegia + hypotension during rewarming — peripheral vasodilation as warming restores perfusion; common in moderate-to-severe hypothermia
Severe hypothermia + cardiac arrest meeting ECMO criteria — witnessed event, no obvious lethal trauma, K typically <12 mmol/L (Brown 2012 + ELSO consensus); ECMO/CPB rewarming offers favourable outcomes even at very low temperatures(life-threatening)

5. Follow-up

Cardiology + EP follow-up if cardiac trigger; endocrinology if myxedema or adrenal disease; substance-use referral if drug/alcohol precipitated; mental health (post-arrest PTSD high risk); social work (homelessness, exposure prevention); rehab for cognitive sequelae

6. Sources

Guideline: AHA 2020 ACLS / Post-Cardiac-Arrest Care hypothermia § + ERC 2021 accidental hypothermia + ELSO accidental hypothermia consensus + Brown 2012 NEJM + Walpoth 1997 NEJM ECMO + TTM2 + HYPERION + Sandroni 2021 neuroprog