Clinical examination for prognostication in comatose cardiac arrest patients

Abstract

Objective To build new algorithms for prognostication of comatose cardiac arrest patients using clinical examination, and investigate whether therapeutic hypothermia influences the value of the clinical examination. Methods From 2000 to 2007, 500 consecutive patients in non-traumatic coma were prospectively enrolled, 200 of whom were post-cardiac arrest. Outcome was determined by modified Rankin Scale (mRS) score at 6 months, with mRS ≤ 3 indicating good outcome. The clinical examination was performed on days 0, 1, 3 and 7 post-arrest, and clinical variables analyzed for importance in prognostication of outcome. A classification and regression tree analysis (CART) was used to develop a predictive algorithm. Results Good outcome was achieved in 9.9% of patients. In CART analysis, motor response was often chosen as a root node, and spontaneous eye movements, pupillary reflexes, eye opening and corneal reflexes were often chosen as splitting nodes. Over 8% of patients with absent or extensor motor response on day 3 achieved a good outcome, as did 2 patients with myoclonic status epilepticus. The odds of achieving a good outcome were lower in patients who suffered asystole (OR 0.187, 95% CI: 0.039–0.875, p = 0.033) compared with ventricular fibrillation or non-perfusing ventricular tachycardia, but some still achieved good outcome. The absence of pupillary and corneal reflexes on day 3 remained highly reliable for predicting poor outcome, regardless of therapeutic hypothermia utilization. Conclusion The clinical examination remains central to prognostication in comatose cardiac arrest patients in the modern area. Future studies should incorporate the clinical examination along with modern technology for accurate prognostication.

Post-anoxic quantitative MRI changes may predict emergence from coma and functional outcomes at discharge

“…Compared with pupillary exam, MRI was superior in predicting persistence of coma. Previous studies show that absence of pupillary reflex is extremely specific but only about 20% sensitive [6], which is consistent with our finding of 16% sensitivity. At 100% specificity, MRI findings had a sensitivity of 68%.…”

“…However, many predictors have been shown to have significant false positive rates in the post-TTM era. Bilaterally absent pupillary light reflexes remain predictive of poor outcome even after TTM [3–6]. More recently, diffusion-weighted imaging (DWI) sequence on magnetic resonance imaging (MRI) has emerged as a potential novel tool to predict recovery [7–11].…”

Effect of Admission Glasgow Coma Scale Motor Score on Neurological Outcome in Out-of-Hospital Cardiac Arrest Patients Receiving Therapeutic Hypothermia

“…4 A recently published RCT comparing normothermia and TH for comatose survivors of out-of-hospital CA performed by Nielsen et al 3 evaluated GCS motor score on admission. Although they reported similar GCS motor scores in the study groups, the association between GCS motor score and neurologic outcome remains unknown.…”

“…8,18,24 Absent or extensor motor responses are no longer reliable predictors of a poor outcome following TH; Greer et al reported that 8.1% of patients with absent or extensor motor responses on day 3 after admission achieved good outcomes. 4 Rossetti et al prospectively evaluated 111 patients treated with TH and observed that a poor motor response on day 3 after admission had a false positivity rate of 24% with regard to predicting poor outcome, 6 but others have reported false positivity rates of 10-17%. 7,8,24 Therefore, because sedatives and paralytics were not administered on admission in the current study, it is theoretically reasonable that the admission GCS motor score of these comatose CA survivors may reliably predict neurologic outcome.…”

Early prognostication markers in cardiac arrest patients treated with hypothermia

“…A study of 111 CA patients found that TH weakened the prognostic accuracy of motor responses , whilst another prospective study showed that neuron‐specific enolase (NSE) levels of >33 μg/l stated in the AAN report guidelines are unreliable for poor outcome prognostication . These findings were also confirmed by other studies and have been attributed to higher sedative use, delayed metabolism of sedatives and neuroprotective effects of TH . Table S1 summarizes recent findings regarding common neurophysiological markers in CA.…”