Therapeutic hypothermia for cardiac arrest: a practical approach

Therapeutic hypothermia (TH), which prevents and ameliorates the cascade of secondary neurologic injury after the return of spontaneous circulation, is the most effective neuroprotective therapy for encephalopathic survivors of cardiac arrest. Despite the compelling efficacy of TH, most patients who survive cardiac arrest long enough to be hospitalized will nonetheless suffer a poor neurologic outcome. Attention to the details of therapy and an integrated approach involving emergency medicine, neurology, cardiology, critical care medicine, and palliative care are likely to yield the best results. This effort is complex, and broad implementation of TH has been slow in the United States and Europe. Given that most cardiac arrest mortality in patients who survive long enough to be hospitalized is due to brain injury rather than circulatory collapse, neurologists should recognize their primary role as advocates for neuroprotective therapy at all stages of the evaluation. In the emergency department, hemodynamic stabilization must be achieved and a rapid neurologic and cardiac evaluation performed, with patients efficiently triaged to hypothermia and cardiac revascularization. Cardiologists should be aware that it is safe and desirable to induce TH, even when urgent coronary angiography and percutaneous revascularization procedures are required. In the intensive care unit, cerebral perfusion must be optimized, metabolic homeostasis achieved, and neuromonitoring used during the dangerous decooling phase. Cardiac arrest is always a life-altering event for patients and their families. Even after cardiac arrest survivors have been stabilized and treated, physicians must recogonize and embrace their role in facilitating a variety of difficult transitions: to organ donation, end-of-life care, nursing or rehabilitation placement, or home.