🩺 THIS WEEK IN EM
Stop Cooling Post-Arrest Patients to 33°C. TTM2 Changed Everything.
The TTM2 trial (NEJM, 2021) randomized 1,850 comatose OHCA survivors at 61 ICUs across 14 countries to targeted hypothermia at 33°C vs. normothermia at ≤37.8°C with aggressive fever treatment.
Mortality at 6 months: 50% hypothermia vs. 48% normothermia — no significant difference. Functional neurological outcomes also equivalent. Hypothermia caused more arrhythmias (24% vs. 16%). This overturns 15+ years of practice driven by two small 2002 trials. The biological rationale was always sound; the clinical benefit never replicated at scale.
The bottom line is clear: fever is bad and must be aggressively prevented — but active cooling to 33°C adds no benefit and harms. Your ICU colleagues may need convincing. Bring the paper.
Bottom line: Target normothermia (≤37.5°C) post-arrest and aggressively treat fever. Active cooling to 33°C is out.
Dankiewicz et al. N Engl J Med. 2021;384(24):2283-2294.
No Immediate Angiography After Arrest Without ST Elevation. Two Trials Agree.
COACT (NEJM, 2019) and TOMAHAWK (NEJM, 2021) both randomized OHCA survivors without ST elevation to immediate vs. delayed coronary angiography. Both showed the same thing: no benefit.
TOMAHAWK (554 patients): 30-day mortality 54% immediate vs. 46% delayed — trending the wrong way. COACT (552 patients): 90-day survival 64.5% vs. 67.2% — no difference. No neurological benefit in either trial.
If there's no STE on the post-ROSC ECG, the cath lab can wait while you stabilize the patient, get brain imaging, and establish goals. Rushing an unstable post-arrest patient to interventional benefits the throughput metrics, not the patient. STEMI on the post-ROSC ECG is still a different story — that goes to the lab.
Bottom line: OHCA without ST elevation does not require immediate angiography — stabilize first, cath later.
Desch et al. N Engl J Med. 2021;385(27):2544-2553.
ECMO for Cardiogenic Shock: Big Machines, Complicated Evidence
ECMO-CS pilot trial (NEJM, 2023): 117 patients with acute cardiogenic shock randomized to early VA-ECMO vs. standard care. Primary composite outcome (resuscitated arrest, mechanical ventilation, RRT, limb ischemia): 37% ECMO vs. 54% no-ECMO — non-significant (p=0.08). 30-day mortality: 41% vs. 40%. Nearly identical.
This was a pilot trial, not powered for mortality. The complication rate with VA-ECMO is real and "ECMO everyone" isn't the answer. The larger ECLS-SHOCK trial will clarify this. For now: early identification of cardiogenic shock, early cardiology, and escalation to an MCS-capable center if you don't have the capability.
Bottom line: VA-ECMO in cardiogenic shock hasn't yet demonstrated a clear mortality benefit — patient selection, timing, and institutional experience are everything.
Ostadal et al. N Engl J Med. 2023;389(9):789-799.
📚 STILL CHANGING PRACTICE
COACT: The Guideline That Changed in Real Time — and Is Still Being Ignored
Worth its own entry because it directly updated ACC/AHA guidelines and is still being bypassed at some centers. COACT (NEJM, 2019): 552 OHCA patients without STE, immediate vs. delayed angiography. 90-day survival and neurological outcomes: equivalent in both arms. Immediate angio caused more contrast use and procedure complications with zero clinical benefit.
This doesn't mean CAD isn't causing the arrest — roughly 50–60% of OHCA patients have significant CAD regardless of rhythm. The question is when to address it, not whether. Planned, systematic angiography after stabilization. The urgency in the absence of STE is manufactured.
Bottom line: 2023 ACC/AHA guidelines now reflect COACT — no STE means stabilize first, cath later.
Lemkes et al. N Engl J Med. 2019;380(15):1397-1407.
Next week: TXA in prehospital trauma — the PATCH trial results weren't the story everyone expected. Plus damage control resuscitation and what PROPPR established about blood product ratios.
The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.