Cite this post as:
Scott Weingart, MD FCCM. Five Minutes with Jon Rittenberger on the TTM Trial. EMCrit Blog. Published on November 18, 2013. Accessed on May 8th 2024. Available at [https://emcrit.org/emcrit/five-minutes-jon-rittenberger-ttm-trial/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: November 18, 2013
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Looks like prehospital TH is going away…thanks science 🙂
In all seriousness, to Dr. Weingart and other viewers, do you all now think that prehospital cooling still has a place? From the TTM article it looks like the median temp on arrival was relatively normal, and the JAMA article found no benefit to prehospital versus in-hospital cooling.
No pre-hospital, post-arrest is probably unnecessary. Intra-arrest is still in play.
Hi Scott, Very interesting, thanks for weighing in. Seems like critical care is moving in a less-is-more direction these days… less hypothermia, less IV fluid resuscitation, less steroids, less Xigris, less intensive insulin, less sedation, less HFOV, less IABP, less transfusion… Currently there is substantial equipoise between 36 and 33 degrees. Since 36 degrees is easier to achieve without a lot of complications/manipulations, my bias would be to favor 36 for most folks while we await more data. Less being more. One fringe benefit of 36 degrees as a target is that it may be possible to prognosticate earlier. It… Read more »
Agree
It is also important to wait for the cognitive outcome study part of TTM to be published. 33 may offer some advantages here despite no difference in survival.
I have to disagree with these studies findings. If you look at the NEJM study, their rates of bystander CPR is 80% and there time to BLS is a mean of 1 minute. Where in America outside of Washington and Arizona do we see these numbers? Their survival to neurologically favorable discharge is also in the 40s – 50s %, again not numbers that are replicated by most communities in the USA.
Until we are producing outcomes and numbers as good as the ones in these studies, I don’t think that we should change hypothermia as of just yet.
Josh,
50% neuro intact survival is pretty much industry standard for V-FIB/V-TACH pts with ROSC. That was seen in the Bernard and HACA trials as well (+-). If you are not achieving this, need to QA post-arrest protocol.
I agree. I think there are a lot of institutions that need to QA their protocols, my own included.
This study might be more of a “perspective changer” than a “practice changer” (though it’s probably a little of both). It probably has always been less about the cold than it is the control. I guess this applies to control of both the temperature itself (i.e. preventing wide temp swings in a brain-injured patient) AND more aggressive control of the effects post-arrest inflammation in general. The latter may also have been at least partially responsible for the difference seen in the “VSE” trial. Unlike in sepsis (when there’s an infection to fight), post-arrest inflammation doesn’t serve much of a purpose… Read more »
Scott,
Was interested in your statement that for the most part you would shoot for 36. Kinda surprised that you are such an early adopter given that the 33 degree threshold is supported by 2 reasonably well done studies of a particular set of ROSC pts and the TTM trial was less particular and more pragmatic I guess. I would think we should wait for replication before jumping on this bandwagon.
UNLESS, there is some backstory to the hypothermia literature which, I will admit, I am woefully unfamiliar with.
Mike.
Mike,
If this study was contradictory to HACA and Bernard, it would require a step back and waiting for more. This study directly supported the conclusion of HACA and Bernard. This was a dose-finding study.
I spoke to some of the medical directors in my state and they brought up to point that most of the systems in our state do not paralyze the patients and they often don’t bolus the fluids and instead infuse the fluid in a little more slowly than done in the study.
Tripp Winslow
Medical Director NC Office of EMS
Wake Forest University Health Sciences
Great stuff as usual Scott. It’ll be interesting to see what the next ILCOR guidelines do with this. Already some speculation.
I got to sit down with Niklas Nielsen and Anders Aneman earlier this evening, so watch out for that podcast on the ICN in the next few days.
See you at SMACC Gold
I am wondering what you are basing the thought to continue to cool sicker or asystole patients to 33. Is there a sub analysis that would support that? Or is it theory based and this study did not demonstrate harm with deeper cooling.