Early prognosis in coma after cardiac arrest: a prospective clinical, electrophysiological, and biochemical study of 60 patients.

Abstract

Background-The univariate study of clinical, electrophysiological, or biochemical variables has been shown to predict the outcome in postanoxic coma in about 50% of patients for each type of variable. Previous studies did not, however, consider the prognostic accuracy of a multivariate approach. Methods-Sixty patients in coma for more than six hours after cardiac arrest were prospectively examined by means of repeated clinical examinations (including Glasgow coma score (GCS)), EEG, and medianus nerve somatosensory evoked potentials (SEPs). In 16 patients, the early concentrations of serum neuron specific enolase and ionised calcium were also measured. Results-Within the first year after cardiac arrest, 20% of patients made a good neurological recovery; 80% remained in a vegetative state or died. Clinical examination correctly predicted outcome in 58% of patients, SEP in 59%, and EEG in 41%. The combination of clinical examination, SEP, and EEG raised the percentage of correct predictions to 82%, without false pessimistic predictions. Concentrations of serum neuron specific enolase and ionised calcium were of no additional prognostic help. Multivariate regression analysis identified the association of GCS < 8 at 48 hours with abnormal or absent early cortical SEPs as highly predictive of a bad outcome (risk = 97%, 95% confidence interval = 86-99%). Conclusion-The combination of GCS at 48 hours, SEP, and if these are nonconclusive, EEG, permits a more reliable prediction of outcome in postanoxic coma than clinical examination alone.

Astroglial Protein S-100 Is an Early and Sensitive Marker of Hypoxic Brain Damage and Outcome After Cardiac Arrest in Humans

“…Within the past few years, various attempts have been made to assess brain damage in comatose patients soon after cardiac arrest. [3][4][5][6][7][8][9][10] Most of them, however, exhibit major limitations. A recent meta-analysis of the clinical and electrophysiological predictors of poor outcome in anoxic-ischemic coma based on data from Ͼ4500 patients suggested that the absence of N20 components of somatosensory evoked potentials in comatose patients with anoxic brain injury and the absence of pain or pupillary responses at 72 hours after cardiac arrest confirm that continuation of life support is futile.…”

“…Various attempts, including neurological evaluation, cranial CT, electroencephalogram, somatosensory evoked potentials, and measurement of cerebral oxygen consumption, have been made to assess brain damage in comatose patients soon after cardiac arrest. [3][4][5][6][7][8][9][10] Early neurological and electrophysiological evaluations, however, do not predict cerebral outcome. 11 A serum marker that reflects the severity of brain damage as accurately as biochemical markers do in myocardial injury, 12 however, would improve early evaluation and quantification of post-cardiac arrest brain damage.…”

Post–Cardiac Arrest Syndrome

“…The N20 component (which represents the primary cortical response) of the SSEP with median nerve stimulation is the best studied evoked-potential waveform in prognostication. 211,256,[293][294][295] In an unresponsive cardiac arrest survivor, the absence of the bilateral N20 component of the SSEP with median nerve stimulation from 24 hours to 1 week after ROSC very reliably predicts poor outcome (FPR for poor outcomeϭ0.7%, 95% CI 0.1% to 3.7%). 254 -256 The presence of the N20 waveform in comatose survivors, however, did not reliably predict a good outcome.…”

“…Some studies have suggested that combining neurological examination with other adjunctive tests enhances the overall accuracy and efficiency of prognostication of poor outcome. 255,293,299,327 No clinical decision rule or multimodal prognostication protocol has been validated prospectively, however.…”

Brain Resuscitation in the Drowning Victim

“…Drowning victims have recovered motor function as late as 48 h after resuscitation [127,128]. CA data supports these findings [70,71,124,129,130]. Following drowning, prediction of poor outcome cannot reliably occur based on absence of pupillary reactivity until 24 h after resuscitation and absence of motor score until 72 h after resuscitation.…”