A 67 year-old man with recently-diagnosed a-fib (on home apixaban) and recent right PCA stroke (about two weeks prior) is brought to the ED after sustaining a cardiac arrest.
He was at home and doing some work on the roof, when he fell to the ground. It's unclear exactly what happened, but a good samaritan was nearby and immediately called for help. He was pulseless when EMS arrived, so they began chest compressions. ROSC was achieved within five minutes.
In the ED, he is greeted by the ED and trauma surgery teams. He undergoes whole-body CT scanning. He is found to have a C4 fracture with severe canal stenosis, T4 compression fracture with moderate canal stenosis, left rib 3-5 fractures, and left hemothorax. Trauma surgery places a left-sided chest tube, with 800mL bloody output. He is admitted to the trauma ICU.
At this point, you are called for recommendations regarding his post-arrest management. On your exam, during which the patient is on propofol gtt and fentanyl gtt, you identify non-reactive pupils, 3mm in diameter each, absent corneal reflex, intact cough reflex, and triple flexion response to noxious stimuli in the extremities.
One of the major questions you might be asked is whether the team should pursue therapeutic hypothermia. This is a pretty controversial subject, and the verdict still isn't out. You've heard of the TTM and TTM2 trials, which found no difference in mortality or functional outcomes at 6 months in comparing 33C vs. 36C and 33C vs. 37.8C, respectively, for patients with out-of-hospital cardiac arrests (OHCA). There are a couple of caveats to this, such as the high rate of bystander CPR and the fact that standardized aggressive care was pursued overall, unlike in the past when perceived futility was even much higher. Specifically, neuroprognostication was standardized and wasn't made until at 96hrs after randomization or later. The most recent 2021 AHA and ILCOR CoSTR guidelines recommend deliberate temperature management, though don't specify any particular targets. Notably, it's recognized that a wide range of temperatures is safe, but there's still insufficient evidence to identify which patients could benefit from a particular temperature range. Considerations such as coagulopathy and need for interventions do play into whether the lower range is pursued.
In this case, the patient has had traumatic injuries and substantial enough bleeding to require chest tube placement. Thus, the primary team here defers therapeutic hypothermia, and instead opts for avoidance of fevers.
In terms of neuroprognostication, it's definitely way too early. We must wait until 48-72 hours after ROSC. It's not surprising to find some absent brainstem reflexes this early in his course; this is meaningless for his prognosis. (If persistent at 72 hours, that's a different story, of course.) In the meanwhile, we can ask them to minimize the use of sedation as much as possible. They can still target the usual physiologic parameters, aiming for normocapnia, normoxia, euglycemia, and normonatremia. There's no evidence-based specific range for each of these. (In the ICU, we generally want 140-180mg/dL, but that's not post-arrest-specific.)
Another recommendation you make is to start continuous EEG. These patients are at high risk of having non-convulsive seizures, and certain electrographic features throughout their course may help you in your prognostication.
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