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cardio.post-arrest.targeted-temperature-management.v1

Post-cardiac-arrest care — TTM protocol (cooling, rewarm, fever prevention)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.post-arrest.core.v1 — narrowed to the TTM operational arc (device, target, sedation, shivering, rewarm, 72h fever prevention). Inherits manifest + design-brief pointer from parent. TTM2 PMID 34133859 supports either 33 °C or 37.5 °C target as non-inferior in shockable OHCA; HYPERION PMID 31532382 supports 33 °C in non-shockable rhythm (NNT 22 for CPC 1-2). ARCTIC Bernard 2022 negative — pre-hospital cooling NOT recommended; cooling begins after sustained ROSC. 5 setting playbooks (ed, icu, inpatient, transition, outpatient). 5 severity triggers covering shivering refractory, post-rewarm hyperthermia, cooling-related coagulopathy, cooling-induced bradycardia, pre-ROSC cooling attempted. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute.

Entry points (3)

  • symptom
    Comatose ROSC patient (GCS motor ≤5) — TTM candidate per TTM2 / HYPERION (AHA 2020 Class I)
    comatose_post_rosc_ttm_candidate
  • vital_abnormality
    Core temperature >37.5 °C post-ROSC requiring active fever prevention (TTM2 PMID 34133859)
    core_temperature_above_37_5_post_rosc
  • history
    ROSC with team decision to initiate TTM device (surface or intravascular) within 4h (Sandroni 2021)
    rosc_with_intent_to_apply_ttm

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Age informs both device selection (intravascular vs surface tolerance) and prognostic discussion timing
  • initial_rhythmrequired
    history • used at CONTEXT
    Shockable → 33 vs 37.5 °C non-inferior per TTM2; non-shockable → favour 33 °C per HYPERION (NNT 22 for CPC 1-2)
  • core_temprequired
    vital • used at TREATMENT
    Continuous bladder/esophageal probe; target reached within 4h, maintained × 24h, then controlled rewarm 0.25-0.5 °C/h (TTM2 PMID 34133859)
  • sbprequired
    vital • used at TREATMENT
    MAP ≥65 during cooling; cooling can drop SBP — pressor titration anticipated (AHA 2020 Class IIa; SOAP-II PMID 20200382)
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia: target SpO2 92-98% (AHA 2020 Class IIa)
  • potassiumrequired
    lab • used at MONITORING
    Hypokalemia common during cooling (intracellular shift); replete to 4-4.5 mmol/L; expect rebound hyperkalemia during rewarm (AHA 2020 Class I)
  • magnesiumrequired
    lab • used at MONITORING
    Mg 2 g IV q6h for shivering control + arrhythmia prevention; cooling drops Mg (Sandroni 2021)
  • glucoserequired
    lab • used at MONITORING
    Cooling causes insulin resistance + hyperglycemia; target 140-180 mg/dL per NICE-SUGAR (PMID 19318384)
  • inr
    lab • used at MONITORING
    Hypothermia-induced coagulopathy at 33 °C; trend INR/PTT/platelets daily (Sandroni 2021)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Cooling causes Osborn (J) waves + QT prolongation; baseline ECG to track
  • lactaterequired
    lab • used at MONITORING
    Lactate clearance trajectory through cooling phase (SCAI 2022 PMID 35718438)
  • creatininerequired
    lab • used at CONTEXT
    AKI common post-arrest + during cooling; drug renal-adjustment (AHA 2020)

12-phase flow (10)

  1. 1FRAME
    TTM operational arc for comatose ROSC patient — device selection (Arctic Sun surface vs Quattro/Coolgard intravascular), target choice (33 °C if HYPERION-non-shockable, 37.5 °C as default per TTM2), and explicit deferral of pre-ROSC cooling per ARCTIC
    inputs: initial_rhythm
    advance: TTM intent confirmed + target temperature chosen
  2. 2ENTRY
    Initiate TTM within 4h of ROSC; insert bladder + esophageal temp probes; activate cooling device (AHA 2020 Class I)
    inputs: age, core_temp
    advance: cooling device active + temp probes in place
  3. 3CONTEXT
    Establish baseline neuro exam off paralytic, current sedation regimen, comorbidities (active bleeding contraindicates 33 °C), advance directives, family contact
    inputs: sbp, spo2, creatinine
    advance: context complete + GOC documented
  4. 4RED_FLAGS
    Active major bleeding (relative contraindication to 33 °C — favour 37.5 °C), refractory shock requiring escalating MCS, refractory arrhythmia, status epilepticus on EEG (AHA 2020; Sandroni 2021)
    inputs: sbp, potassium
    actions: protocol.cardiogenic_shock
    advance: red flags screened + target temperature locked
  5. 5INITIAL_WORKUP
    Baseline ECG (Osborn waves + QTc), CBC + BMP + Mg + Phos + Ca + INR + lactate + ABG; CXR for ETT placement; bedside echo for LV/RV (AHA 2020)
    inputs: ecg_12_lead, potassium, magnesium, glucose, lactate, creatinine
    actions: post_arrest_care, panel.cardiac, panel.renal
    advance: baseline labs + ECG + echo documented
  6. 6BRANCHING_WORKUP
    STEMI on baseline ECG → emergent cath in parallel with TTM (AHA 2020 Class I); refractory VF arrest → ECPR per ARREST (PMID 33308475); both pathways are compatible with simultaneous TTM
    actions: acs_pathway
    advance: parallel reperfusion / ECPR decisions made
  7. 7TREATMENT
    TTM induction phase: target reached within 4h via surface (Arctic Sun) or intravascular (Quattro/Coolgard) cooling; sedation propofol 5-50 µg/kg/min + fentanyl 25-200 µg/h (PADIS 2018); shivering control BSAS-driven (Mg 2g IV q6h + buspirone 30mg PO q8h + cisatracurium 1-3 µg/kg/min if refractory); maintenance × 24h at chosen target (33 °C for HYPERION-non-shockable, 37.5 °C default per TTM2); controlled rewarm 0.25-0.5 °C/h over 8-12h; post-rewarm fever prevention × 72h with continued device or acetaminophen (TTM2 PMID 34133859; HYPERION PMID 31532382; Sandroni 2021)
    inputs: core_temp, sbp, spo2, potassium, magnesium
    advance: TTM phase complete (induction → maintenance → controlled rewarm → 72h fever prevention)
  8. 8DISPOSITION
    CICU/ICU-level care throughout TTM; cardiology + critical care co-management; daily neuro exam during fever-prevention phase off sedation
    advance: unit assigned + TTM phase tracking documented
  9. 9MONITORING
    Continuous core temp (bladder/esophageal); continuous EEG ×24-48h for status epilepticus; BSAS q1h; lactate q2-4h; BMP + Mg + Phos + Ca q6-12h; glucose q1-2h on insulin; INR/PTT daily; daily neuro exam after rewarm; NSE at 24/48/72h; SSEP N20 + MRI brain at ≥72h post-rewarm for multimodal neuroprog (Sandroni ERC-ESICM 2021 PMID 33745427)
    inputs: potassium, magnesium, glucose, inr, core_temp
    actions: panel.renal, panel.cardiac
    advance: monitoring plan + neuroprog timeline documented
  10. 10FOLLOWUP
    Post-TTM cognitive screen at d/c + 3 mo; neuropsychology referral if anoxic injury; cardiac rehab; hand-off to long-term cardiology + EP if structural disease (AHA 2020)
    advance: cognitive + cardiology + EP follow-up booked