All in a lather over TTM

In case you have been hiding under a rock the last 72 hours…here is a run down on Targeted Temperature Management (TTM) – not to try and sell you either way, but to highlight the amazing way in which the conversation has evolved.

I am really interested in the outcomes of the discussion – but even more interested in the way the discussion takes place – the way the evidence is dissected and the means by which the global community rally together to debate the future direction of TTM and other pressing issues.

Papers are published then discussed and dissected, whilst the controversial aspects, the stats, the machinations and the implications are all openly being evaluated on a global scale in real time – as a persistent 24/7/365 journal club

There was a time not so long ago that the Journals were inaccessible online, a paper version had to be ordered, distributed and debated in parochial isolated silos over weeks and months…now we see the process happening in real time, online…immediately through FOAM

  • Distribution – free open access articles, online ahead of print
  • Dissemination – twitter, podcast, blog
  • Discussion – FOAMed groups, social media platforms
  • Analysis – academic analysis, statistical review and commentary
  • Debate – TTM survey, storify, FOAM


The key articles are freely available online – easy to access, review, analyse and share.

Key articles in the TTM debate
  • Bernard SA et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-63. doi: 10.1056/NEJMoa003289
  • The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549-56. doi: 10.1056/NEJMoa012689
  • Nielsen N et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med Nov 17 2013 doi: 10.1056/NEJMoa1310519
  • Rittenberger JC, Callaway CW. Temperature Management and Modern Post–Cardiac Arrest Care. N Engl J Med Nov 17 2013 doi: 10.1056/NEJMe1312700
  • Kim F et al. Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac ArrestA Randomized Clinical Trial. JAMA Nov 17 2013 doi:10.1001/jama.2013.282173
  • Granger CB, Becker LB. Randomized Clinical Trial Progress to Inform Care for Out-of-Hospital Cardiac Arrest. JAMA Nov 17 2013 doi:10.1001/jama.2013.282174


  • The telegram is dead.
  • Long live podcasts, blogs and FOAM

EM:RAP Audio – On the morning of publication the inimitable Mel Herbert of EM:RAP gave us a brief summary update of the hypothermia debate.

EMcrit Audio – Scott Weingart provides enlightening commentary on the major issues in critical care, interviewing the leading lights in critical care. He provided an early EMCrit Wee on TTM

…and then got straight on the line with Jon Rittenberger

The SGEM Audio – Ken Milne put the TTM concept into clinical context adding the JAMA article to the debate

Backed up with myriad blogposts including KIDocs, AmboFOAM, ResusMe, ScanCrit, EMLit of Note, Emergence Phenomena, just to name a few – all with different target audiences and differing points of view…but with one common aim of disseminating the information and promoting discussion.


Then we have the UberNerds with the statistical analysis, the in depth review of the power and the stats. The academic reprise if you will. Now I don’t understand statistics very well, and in the past would read every paper as gospel bowing to the greater analytical academic minds that wrote, reviewed and analysed the data – but not anymore. Now we have open discussion on every element from study design, to power analysis and detailed statistical evaluation.

  • TTM and OOHCA cooling evidence – “Sorry folks, but this is a negative study of difference NOT a positive study of similarity…”
  • The Adventure of the Empty House” Well before Han Solo was frozen in carbonite, before Sigourney Weaver crossed galaxies in cryostasis, or Walt Disney was cryopreserved, we have been fascinated by the stasis-like powers of hypothermia…

The power is not just in the posts and podcasts – but in the commentary and discussion inline through comments and online throughout the blogosphere on twitter, Facebook, G+ and beyond. It really is an amazing opportunity for us to take emergency medicine and critical care management to the next level of understanding and practice.

To change or not to change – good evidence or poor analysis – we now have a place to debate the outcome and be part of the development of Critical Care management moving forward. Journals are not dead, textbooks are not dead, academic peer-review is not dead…we have just fundamentally changed the way we can distribute, disseminate, discuss, debate and analyse medical education and research…forever

Glossary of Terms:

  • OOHCA – Out Of Hospital Cardiac Arrest
  • ROSC – Return Of Spontaneous Circulation
  • TTM – Targeted Temperature Management

CCC 700 6

Critical Care


BA MA (Oxon) MBChB (Edin) FACEM FFSEM. Emergency physician, Sir Charles Gairdner Hospital.  Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.