A 52-year-old man with SSc, RP, ischemic cardiomyopathy, and recent cocaine use developed cardiopulmonary arrest with ventricular fibrillation. Cardiopulmonary resuscitation was administered with return of spontaneous circulation within 20 min. Postarrest, he showed no eye or verbal response, but was withdrawing to pain, corresponding to a Glasgow Coma Scale of 6. He was hemodynamically stable with minimal use of pressors. Chronic superficial digital ulcers were present on all fingertips. Laboratory tests revealed an elevated troponin level and leukocytosis. ECG and transthoracic echocardiogram showed no evidence of acute ischemia. Therapeutic hypothermia was induced via surface cooling to a temperature of 33°C for 24 h, followed by gradual rewarming. During the cooling phase, nonblanching erythema developed on the dorsum of the feet, ankles, wrists, and tibial surfaces (Figs 1A, 1B). Dusky necrosis developed on the left fourth digit 72 h later (Fig 1C). Nifedipine was administered. He regained full neurologic function. Cardiac catheterization revealed nonobstructive coronary artery disease. An automatic implantable cardioverter defibrillator was implanted. Skin findings, except for the fingertip necrosis (Fig 2), had substantially improved by hospital discharge to home.