Targeted Temperature for Non-shockable Rhythm

Written by Thomas Davis

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If you’re a proponent of bystander CPR, you should probably also be a strong advocate for targeted temperated management (TTM) for non-shockable rhythm.

Why does this matter?
The 2015 AHA guidelines recommend TTM (32-36C) for all adult patients after ROSC who are comatose (i.e. lack of meaningful response to verbal commands). However, this endorsement of TTM for non-shockable rhythm is based on expert opinion and flimsy evidence. Retrospective case-series have shown conflicting results ranging between benefit, no benefit, and even harm. Therefore, a large randomized study has been long overdue.

Ice is back with a brand new invention.
Analyzing patients who achieved ROSC after a nonshockable rhythm, this study compared moderate hypothermia (33C) to normothermia (37C). It was a pragmatic, open-label, randomized, controlled trial. It included 581 patients from 25 French ICUs. Three-quarters of patients had out-of-hospital cardiac arrest. Two-thirds were presumed to have a non-cardiac etiology. The primary outcome was 90-day survival with a favorable neurologic outcome, defined as a CPC score of 1 or 2. They found 10.2% of the hypothermia protocol patients had a good neurologic outcome whereas only 5.7% in the normothermia group had a good neurologic outcome (absolute difference 4.5%, 95% CI 0.1% – 8.9%, p = 0.04). This equates to a NNT = 22. To put this in perspective, the NNT to prevent one death with bystander CPR is 15 and with epinephrine is 112.

Source
Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. N Engl J Med. 2019 Oct 2. doi: 10.1056/NEJMoa1906661. [Epub ahead of print]

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Reviewed by Clay Smith

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