Targeted Temperature Management & Post-Cardiac Arrest Care

ABPN Neurocritical Care Study Guide Exam

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1 Chapter 1: Neurologic Examination & Coma Assessment in the ICU

Current Examination, Blueprint & Preparation Neurologic Examination in Critically Ill Patients Coma Evaluation & Consciousness Alterations Delirium & Toxic-Metabolic Encephalopathy in the ICU

2 Chapter 2: Cerebral Physiology & Intracranial Dynamics

Cerebral Blood Flow, Metabolism & Autoregulation Intracranial Pressure & Compliance Cerebral Edema & Herniation Syndromes

3 Chapter 3: Intracranial Hypertension & Cerebral Perfusion Management

Tiered ICP Management Protocols Hyperosmolar Therapy & Fluid Management Advanced & Refractory ICP Interventions

4 Chapter 4: Airway, Mechanical Ventilation & Pulmonary ICU Management

Emergency Airway Management & Neuro-Intubation Mechanical Ventilation Strategies in Acute Brain Injury Tracheostomy & Ventilator Weaning in Neurocritical Care Pulmonary Complications in the Neuro-ICU Obstructive Lung Disease, Pulmonary Hypertension & Bronchoscopy

5 Chapter 5: Hemodynamics, Shock & Cardiovascular Management

Hemodynamic Monitoring & Blood Pressure Targets Vasoactive Agents: Inotropes, Vasopressors & Antihypertensives Cardiac Complications of Brain Injury

6 Chapter 6: Neuropharmacology, Analgesia & Sedation

ICU Sedation & Analgesia Neuromuscular Blockade & Monitoring Propofol Infusion Syndrome & Drug Toxicities Antiseizure Drug Pharmacology in the ICU

7 Bleeding, Thrombosis & Hematologic Emergencies

Warfarin & Heparin Reversal Direct Oral Anticoagulant (DOAC) Reversal Antiplatelet Management & Platelet Dysfunction Venous Thromboembolism Prophylaxis & Management Transfusion, Coagulopathy, TMA & Cellular-Therapy Neurotoxicity

8 Chapter 8: Systemic ICU Care, Fluids, Electrolytes & Endocrine

Hyponatremia & Osmoregulation: SIADH vs Cerebral Salt Wasting Diabetes Insipidus, Hypernatremia & Endocrine Crises Critical Care Prophylaxis, Nutrition & Infection Prevention

9 Systemic Trauma & Environmental Injury

Polytrauma, Chest Injury & Abdominal Hemorrhage Burns, Electrical Injury & Hanging

10 Cardiac Emergencies & Mechanical Support

IABP, Ventricular Devices & ECMO Acute Coronary, Valvular, Rhythm & Aortic Emergencies

11 Kidney Injury, Acid–Base & Renal Replacement

Acute Kidney Injury & Renal Drug Clearance Acid–Base Disorders, Electrolytes & Renal Replacement

12 Systemic Infection & Endocrine Emergencies

Sepsis, Endocarditis & Antimicrobial Principles Thyroid, Adrenal & Dysglycemic Emergencies

13 Gastrointestinal & Hepatic Emergencies

Acute Abdomen, GI Bleeding & Abdominal Compartment Syndrome Acute Liver Failure, Cirrhosis & Hepatic Drug Effects

14 Chapter 9: Neuroimaging in the Neuro-ICU

Non-Contrast CT & CT Angiography CT Perfusion & Advanced Perfusion Imaging Magnetic Resonance Imaging in Critical Illness

15 Chapter 10: Electrophysiology & Neuromonitoring

Continuous EEG & ACNS Standardized Critical Care Terminology Invasive Neuromonitoring: ICP & External Ventricular Drains Multimodal Monitoring: PbtO2, Microdialysis & Transcranial Doppler

16 Angiography, Electrodiagnosis & CSF Analysis

Conventional Angiography & Cranial–Spinal Shunts EMG, Nerve Conduction & Acute Muscle Disease CSF Analysis: Infection, Inflammation & Hemorrhage

17 Chapter 11: Bedside Procedures, Ultrasound & Death by Neurologic Criteria

Critical Care Procedural Skills Critical Care Ultrasound & Echocardiography Determination of Death by Neurologic Criteria

18 Chapter 12: Acute Ischemic Stroke & Reperfusion Therapies

Acute Ischemic Stroke Management & Thrombolysis Endovascular Thrombectomy & Large Vessel Occlusion Malignant Hemispheric & Cerebellar Infarction

19 Chapter 13: Spontaneous Intracerebral Hemorrhage & Intraventricular Hemorrhage

Acute Intraparenchymal Hemorrhage Management Intraventricular Hemorrhage & Hydrocephalus Surgical Evacuation & Minimally Invasive Surgery in ICH

20 Chapter 14: Aneurysmal Subarachnoid Hemorrhage & Delayed Cerebral Ischemia

Aneurysmal Subarachnoid Hemorrhage: Acute Resuscitation & Securing Delayed Cerebral Ischemia & Cerebral Vasospasm Non-Aneurysmal Subarachnoid Hemorrhage & Vascular Malformations

21 Venous, Spinal & Traumatic Vascular Disease

Cerebral Venous Thrombosis & Spinal Cord Infarction Traumatic Dissection, Carotid–Cavernous Fistula & Penetrating Injury

22 Chapter 15: Traumatic Brain & Spinal Cord Injury

Severe Traumatic Brain Injury & Contusions Acute Traumatic Spinal Cord Injury & Neurogenic Shock Spine Trauma, Fractures & Cord Syndromes

23 Chapter 16: Status Epilepticus, Seizures & Neuromuscular Emergencies

Status Epilepticus: Convulsive & Non-Convulsive Refractory & Super-Refractory Status Epilepticus Acute Neuromuscular Respiratory Failure

24 Chapter 17: Post-Cardiac Arrest Care, CNS Infections & Encephalitis

Targeted Temperature Management & Post-Cardiac Arrest Care Post-Cardiac Arrest Neuroprognostication Acute CNS Infections, Encephalitis & Inflammatory Emergencies

25 Neuroinflammation & Neurooncology

Fulminant Demyelination & Autoimmune Encephalitis Brain, Spinal & Leptomeningeal Cancer Emergencies

26 Pregnancy, Transplantation & Pediatric Care

Pregnancy, Postpartum & Post-Transplant Neurologic Care Pediatric Neurocritical Care

27 Chapter 18: Neurosurgical & Perioperative Emergencies

Postoperative Neurosurgical Complications Device Complications: EVDs, Shunts & ICP Monitors Cerebral Hyperperfusion Syndrome & Post-Interventional Emergencies

28 Chapter 19: Ethics, Palliative Care & Organ Donation in the Neuro-ICU

Communication, Surrogate Decision-Making & Conflict Resolution Neuroprognostication Ethics, Withdrawal of Life Support & Palliative Care Organ Donation & Management of the Deceased Donor

Targeted Temperature Management & Post-Cardiac Arrest Care

Key Takeaways Explain This Topic AI

Adults unresponsive to verbal commands after ROSC need a deliberate temperature-control strategy targeting 32–37.5 °C; at least 36 hours of total temperature control is reasonable.

Once reliable measurements are available, the 2025 AHA algorithm targets SpO2 90–98%, PaO2 60–105 mm Hg, and PaCO2 35–45 mm Hg.

Maintain MAP at least 65 mm Hg and individualize further support to organ perfusion and shock physiology.

TTM2 did not show superiority of 33 °C over controlled normothermia and reported more hemodynamically important arrhythmias with hypothermia.

Last updated: October 2026

• Temperature and Physiology After Cardiac Arrest
• The First Assessment After ROSC

Post-cardiac arrest syndrome includes brain injury, myocardial dysfunction, systemic ischemia–reperfusion effects, and the disease that caused the arrest. A pulse does not complete resuscitation. Confirm airway and ventilation, obtain reliable oxygenation and blood pressure measurements, record a twelve-lead ECG, and evaluate for coronary occlusion, pulmonary embolism, hemorrhage, toxic exposure, or another cause. Emergency coronary intervention depends on the ECG and clinical instability; it is not an automatic immediate procedure for every stable patient without ST elevation.

Treat hypotension and impaired perfusion while defining the shock phenotype. Assess rhythm, bedside cardiac function, volume responsiveness, lactate trend, urine output, and examination. The 2025 AHA approach maintains MAP at least 65 mm Hg. Some patients need an individualized higher goal, but a history of hypertension does not automatically prove that MAP 66 is inadequate or mandate 80–100. Choose fluids, vasopressors, and inotropes according to vasodilation, ventricular function, congestion, and response. Prevent recurrent arrest during transport and procedures.

Oxygenation and Ventilation

Use 100% inspired oxygen initially until oxygenation can be measured reliably. Once dependable saturation or arterial measurements are available, titrate oxygen to avoid both hypoxemia and unnecessary hyperoxemia. The 2025 AHA adult algorithm uses SpO2 90–98% and PaO2 60–105 mm Hg. Pulse oximetry may be inaccurate during low perfusion or with other measurement limitations; check the signal and use arterial gases when needed. Do not abruptly reduce oxygen on the basis of an unreliable display.

Target PaCO2 35–45 mm Hg in most comatose adults. Hypocapnia can reduce cerebral blood flow; uncontrolled hypercapnia can increase cerebral blood volume and worsen intracranial pressure. End-tidal CO2 is useful for trends but may diverge substantially from PaCO2 after arrest because of dead space and circulatory failure. Obtain gases after meaningful ventilator changes and use lung-protective ventilation adjusted to the patient. Avoid treating a low end-tidal value as proof that arterial CO2 must also be low.

For example, PaO2 285 and PaCO2 28 on FiO2 1.0 suggest excessive oxygen exposure and ventilation once measurements are reliable. Gradually reduce FiO2 and minute ventilation toward the supported ranges while monitoring oxygenation and repeat gases. MAP 66 meets the guideline minimum, but still warrants evaluation of the actual perfusion state; it does not independently mandate a particular pressor dose.

Temperature Strategy and Evidence

Adults unresponsive to verbal commands after ROSC should receive a deliberate temperature-control strategy with a selected temperature between 32 and 37.5 °C. At least 36 hours of total temperature control is reasonable in this group. This is not necessarily 36 hours at one hypothermic target followed by a separately mandated additional 72-hour phase. Plan ongoing fever surveillance and prevention according to the clinical course and protocol. Avoid rapid active rewarming of a spontaneously hypothermic patient.

Early hypothermia trials in selected shockable out-of-hospital arrests supported improved neurologic outcomes, but differed in enrollment, cooling duration, and outcome timing. They should not be summarized as identical trials with the same mortality result. TTM1 did not demonstrate a significant outcome difference between targets of 33 and 36 °C. HYPERION reported a modest favorable neurologic outcome signal in nonshockable arrests without a significant mortality reduction; later evidence and population differences limit broad extrapolation.

TTM2, led by Dankiewicz and colleagues, compared 33 °C with normothermia and early fever treatment after out-of-hospital arrest. Six-month mortality was 50% versus 48%, without a significant difference; moderately severe disability or worse, measured by mRS at least 4, occurred in 55% of both groups. Hemodynamically compromising arrhythmias were more frequent with hypothermia, 24% versus 17%. A neutral superiority trial does not prove exact equivalence or exclude every possible subgroup effect. It supports selecting a controlled strategy without claiming universal superiority of 33 °C.

Deliver Control Safely

Use a reliable core temperature site and a protocol appropriate to surface or intravascular devices. Check skin, access sites, device function, and infection risk. Large rapid cold crystalloid infusions are not a routine post-arrest cooling strategy. Monitor potassium and other electrolytes, glucose, rhythm, coagulation, and drug accumulation during cooling and rewarming. Hypothermia can prolong sedative effects, which must be considered later in prognostication.

Shivering increases metabolic demand and can prevent temperature control. Assess it by examination, palpation, and a consistent bedside scale. Begin with appropriate skin counter-warming and analgesia, then use protocol-based medication while considering organ function, interactions, and hemodynamics. Acetaminophen dosing depends on liver function and total exposure; magnesium requires renal and level monitoring. Buspirone and other agents are protocol options rather than a mandatory fixed-dose bundle. Meperidine's neurotoxic metabolite is a particular concern with renal impairment.

If deep sedation or neuromuscular blockade is necessary for refractory shivering, provide adequate analgesia and hypnosis before paralysis. Paralysis hides convulsions and bedside motor responses; EEG monitoring is particularly important when seizures are suspected or examination is unavailable. Use the minimum effective blockade and reassess. Continue seizure assessment, nutrition, thromboprophylaxis, infection evaluation, and family communication. Temperature management does not establish prognosis, and early coma or myoclonus alone does not establish futility.

Source: 2025 AHA adult post-arrest care algorithm and TTM2 trial .

Decision Review

• Parameter 2025 AHA adult approach
• Oxygen after reliable measurement SpO2 90–98% and PaO2 60–105 mm Hg
• Ventilation PaCO2 35–45 mm Hg in most comatose adults
• Pressure MAP at least 65 mm Hg, with further support individualized
• Temperature Deliberate target 32–37.5 °C; at least 36 hours of total control reasonable