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cardio.post-arrest.targeted-temperature-management.v1PRODUCTION
cardio.post-arrest.targeted-temperature-management.v1

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

cardiologyacuteadult
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Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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

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Advance when

TTM intent confirmed + target temperature chosen

Patient inputs (12)

Age informs both device selection (intravascular vs surface tolerance) and prognostic discussion timing

Shockable → 33 vs 37.5 °C non-inferior per TTM2; non-shockable → favour 33 °C per HYPERION (NNT 22 for CPC 1-2)

AKI common post-arrest + during cooling; drug renal-adjustment (AHA 2020)

Cooling causes Osborn (J) waves + QT prolongation; baseline ECG to track

Hypokalemia common during cooling (intracellular shift); replete to 4-4.5 mmol/L; expect rebound hyperkalemia during rewarm (AHA 2020 Class I)

Mg 2 g IV q6h for shivering control + arrhythmia prevention; cooling drops Mg (Sandroni 2021)

Cooling causes insulin resistance + hyperglycemia; target 140-180 mg/dL per NICE-SUGAR (PMID 19318384)

Lactate clearance trajectory through cooling phase (SCAI 2022 PMID 35718438)

Continuous bladder/esophageal probe; target reached within 4h, maintained × 24h, then controlled rewarm 0.25-0.5 °C/h (TTM2 PMID 34133859)

MAP ≥65 during cooling; cooling can drop SBP — pressor titration anticipated (AHA 2020 Class IIa; SOAP-II PMID 20200382)

Avoid hyperoxia: target SpO2 92-98% (AHA 2020 Class IIa)

Hypothermia-induced coagulopathy at 33 °C; trend INR/PTT/platelets daily (Sandroni 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationalsevereshivering_refractory_to_full_bundle
    BSAS ≥2 despite propofol 50 µg/kg/min + fentanyl 200 µg/h + Mg 2g q6h + buspirone 30 mg q8h
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehyperthermia_post_rewarm
    Core temp ≥38 °C during 72h post-rewarm fever-prevention phase
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecooling_related_coagulopathy_with_bleeding
    INR >1.5 or PTT >50 + active bleeding during 33 °C cooling phase
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecooling_induced_bradycardia_with_hypotension
    HR <40 + SBP <90 during cooling phase
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepre_rosc_cooling_attempted
    EMS or ED initiated cooling before sustained ROSC
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

TTM protocol phenotype — target choice + sedation + shivering control + fever prevention (TTM2 + HYPERION + Sandroni 2021)
axis: ttm_protocol_phenotype
Selected axis "TTM protocol phenotype — target choice + sedation + shivering control + fever prevention (TTM2 + HYPERION + Sandroni 2021)" by default fallback (first axis)
  • propofol
    first line
    sedative_gaba_a_agonist
    5-50 µg/kg/min IV • IV • continuous; titrate to RASS -4 to -5 during cooling
    triggers: ttm_started, intubated_post_rosc
    PADIS 2018 PMID 30113379 — preferred sedative for TTM; rapid offset enables daily neuro exam during rewarm + fever-prevention phase
    rxcui 8782
  • fentanyl
    first line
    opioid_analgesic
    25-100 µg IV bolus → 25-200 µg/h infusion • IV • continuous
    triggers: ttm_started, intubated_post_rosc
    PADIS 2018; complements propofol; cooling reduces fentanyl clearance — anticipate dose reduction during maintenance phase
    rxcui 4337
  • magnesium sulfate
    first line
    electrolyte_anti_arrhythmic
    2 g IV q6h scheduled during cooling phase • IV • q6h scheduled
    triggers: ttm_active, shivering_present_or_anticipated
    BSAS-driven anti-shivering + arrhythmia prevention (cooling drops Mg); Sandroni 2021
    rxcui 6585
  • buspirone
    add on
    5HT1A_partial_agonist
    30 mg PO/NG q8h scheduled during cooling • PO/NG • q8h
    triggers: shivering_BSAS_2_or_above
    Anti-shivering adjunct to reduce sedative requirement (Choi NCC 2011)
    rxcui 1827
  • cisatracurium
    rescue
    neuromuscular_blocker
    0.15 mg/kg load → 1-3 µg/kg/min infusion • IV • continuous
    triggers: refractory_shivering_despite_propofol_fentanyl_mg_buspirone, ventilator_asynchrony_during_cooling
    Used only with adequate sedation; minimize duration to enable neuro exam during rewarm (Sandroni 2021)
    rxcui 136561
  • norepinephrine
    first line
    vasopressor
    0.05 µg/kg/min IV → titrate MAP ≥65 • IV • continuous
    triggers: cooling_induced_hypotension, post_rosc_vasoplegia
    AHA 2020 Class IIa; SOAP-II PMID 20200382 — preferred over dopamine in shock
    rxcui 7512
  • acetaminophen
    first line
    analgesic_antipyretic
    650-1000 mg PO/IV q6h scheduled during 72h post-rewarm fever prevention • PO/IV • q6h × 72h post-rewarm
    triggers: post_rewarm_fever_prevention_phase, core_temp_above_37_5
    TTM2 PMID 34133859 — fever prevention × 72h is the key intervention; Sandroni 2021
    rxcui 161

outpatient playbook — drug actions (2)

  1. 1. GDMT maintenance for HFrEF
    rxcui 1656328
    ARNI + BB + MRA + SGLT2i at max tolerated • PO • as scheduled
    trigger: HFrEF post-arrest
    ACC/AHA 2022 HF 4-pillar
  2. 2. high-intensity statin maintenance
    rxcui 83367
    atorvastatin 80 mg daily • PO • daily
    trigger: CAD
    IMPROVE-IT PMID 26039521

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Comatose ROSC patient (GCS motor ≤5) — TTM candidate per TTM2 / HYPERION (AHA 2020 Class I); Core temperature >37.5 °C post-ROSC requiring active fever prevention (TTM2 PMID 34133859); ROSC with team decision to initiate TTM device (surface or intravascular) within 4h (Sandroni 2021).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Post-cardiac-arrest care — TTM protocol (cooling, rewarm, fever prevention)** (cardio.post-arrest.targeted-temperature-management.v1).
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **TTM protocol phenotype — target choice + sedation + shivering control + fever prevention (TTM2 + HYPERION + Sandroni 2021)**.
1. propofol 5-50 µg/kg/min IV IV continuous; titrate to RASS -4 to -5 during cooling (sedative_gaba_a_agonist, first line) — PADIS 2018 PMID 30113379 — preferred sedative for TTM; rapid offset enables daily neuro exam during rewarm + fever-prevention phase
2. fentanyl 25-100 µg IV bolus → 25-200 µg/h infusion IV continuous (opioid_analgesic, first line) — PADIS 2018; complements propofol; cooling reduces fentanyl clearance — anticipate dose reduction during maintenance phase
3. magnesium sulfate 2 g IV q6h scheduled during cooling phase IV q6h scheduled (electrolyte_anti_arrhythmic, first line) — BSAS-driven anti-shivering + arrhythmia prevention (cooling drops Mg); Sandroni 2021
4. buspirone 30 mg PO/NG q8h scheduled during cooling PO/NG q8h (5HT1A_partial_agonist, add on) — Anti-shivering adjunct to reduce sedative requirement (Choi NCC 2011)
5. cisatracurium 0.15 mg/kg load → 1-3 µg/kg/min infusion IV continuous (neuromuscular_blocker, rescue) — Used only with adequate sedation; minimize duration to enable neuro exam during rewarm (Sandroni 2021)
6. norepinephrine 0.05 µg/kg/min IV → titrate MAP ≥65 IV continuous (vasopressor, first line) — AHA 2020 Class IIa; SOAP-II PMID 20200382 — preferred over dopamine in shock
7. acetaminophen 650-1000 mg PO/IV q6h scheduled during 72h post-rewarm fever prevention PO/IV q6h × 72h post-rewarm (analgesic_antipyretic, first line) — TTM2 PMID 34133859 — fever prevention × 72h is the key intervention; Sandroni 2021

Setting playbook (outpatient) — Long-term cognitive + cardiac surveillance; GDMT maintenance; ICD/WCD management; mental health follow-up
8. GDMT maintenance for HFrEF ARNI + BB + MRA + SGLT2i at max tolerated PO as scheduled — HFrEF post-arrest (ACC/AHA 2022 HF 4-pillar)
9. high-intensity statin maintenance atorvastatin 80 mg daily PO daily — CAD (IMPROVE-IT PMID 26039521)

Non-pharmacologic actions:
- Cardiac rehab maintenance phase
- Ongoing CPR/AED training for family
- Driving restriction per state law

AVOID / contraindication checks:
- Hypothermia_avoid_pre_ROSC_cooling (ARCTIC Bernard 2022 — pre hospital cooling negative; do NOT cool before ROSC)
- 33C_relative_avoid_active_major_bleeding (cooling induced coagulopathy worsens bleeding; favour 37.5 °C target)
- Hyperthermia_avoid_post_rewarm × 72h (TTM2 PMID 34133859)
- Hyperoxia_avoid_post_rosc (AHA 2020 Class IIa: SpO2 92 98%)
- Cisatracurium_minimize_duration_to_preserve_neuro_exam (Sandroni 2021)

Monitoring

Regimen monitoring:
- continuous core temp via bladder or esophageal probe (TTM2 PMID 34133859)
- BSAS q1h during cooling phase (Sandroni 2021)
- BMP q6h + Mg + Phos + Ca + ionized Ca during cooling
- glucose q1-2h on insulin (cooling causes insulin resistance)
- INR PTT platelets daily (cooling-induced coagulopathy)
- continuous EEG for status epilepticus 24-48h (Sandroni 2021)
- NSE at 24h 48h 72h (Sandroni 2021)
- SSEP N20 bilateral at 72h after rewarm (Sandroni 2021)
- MRI brain days 2-7 for diffuse anoxic injury (Sandroni 2021)
- core temp q1h during 72h fever prevention phase (TTM2)

Setting (outpatient) monitoring:
- Quarterly BP + weight + symptom score
- Annual ECG ± Holter if structural disease
- Annual echo if HFrEF

Follow-up plan: 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)
- Close-out criterion: cognitive + cardiology + EP follow-up booked

Monitoring phase: 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)

Disposition

Current setting: outpatient — Long-term cognitive + cardiac surveillance; GDMT maintenance; ICD/WCD management; mental health follow-up

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if HFrEF persists

Escalation triggers (move to higher acuity):
- ICD therapy delivered → urgent EP
- EF declining despite GDMT → advanced HF eval
- New cognitive decline / depression / PTSD → mental health referral

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] BSAS ≥2 despite propofol 50 µg/kg/min + fentanyl 200 µg/h + Mg 2g q6h + buspirone 30 mg q8h
- [SEVERE] Core temp ≥38 °C during 72h post-rewarm fever-prevention phase
- [SEVERE] INR >1.5 or PTT >50 + active bleeding during 33 °C cooling phase

Citations

- 2020 AHA ACLS / Post-Cardiac-Arrest Care + 2021 ERC-ESICM Post-Resuscitation Guideline [PMID:33081530](https://pubmed.ncbi.nlm.nih.gov/33081530/)
- Cited evidence (PMID 24237006) [PMID:24237006](https://pubmed.ncbi.nlm.nih.gov/24237006/)
- Cited evidence (PMID 34133859) [PMID:34133859](https://pubmed.ncbi.nlm.nih.gov/34133859/)
- Cited evidence (PMID 31532382) [PMID:31532382](https://pubmed.ncbi.nlm.nih.gov/31532382/)
- Cited evidence (PMID 33745427) [PMID:33745427](https://pubmed.ncbi.nlm.nih.gov/33745427/)

Last reconciled with current guidelines: 2026-05-14.
References