Abstract
Background
Recent advances in post–cardiac arrest (CA) care including therapeutic hypothermia
(TH) have improved survival and favorable neurologic outcomes for survivors of CA.
Survivors often present with deep coma and lack of brainstem reflexes, which are generally
associated with adverse outcomes in many disease processes. Little is known regarding
the role of initial emergency department (ED) neurological examination and its potential
for prognostication.
Objectives
The purpose of this study is to determine if components of a standardized neurologic
examination are reliable prognosticators in patients recently resuscitated from CA.
We hypothesize that lack of neurologic function does not reliably predict an adverse
outcome and, therefore, should not be used to determine eligibility for TH.
Methods
A standardized neurologic examination was performed in the ED on a prospective, convenience
cohort of post-CA patients presenting to a CA resuscitation center who would undergo
a comprehensive postarrest care pathway that included TH. Data such as prior sedation
or active neuromuscular blockade were documented to evaluate for the presence of possible
confounders. Examination findings were then compared with hospital survival and neurologic
outcome at discharge as defined by the cerebral performance category (CPC) score as
documented in the institutional TH registry.
Results
Forty-nine subjects were enrolled, most of whom presented comatose with a Glasgow
Coma Scale of 3 (n = 41, 83.7%). Nineteen subjects (38.8%) had absence of all examination findings, of
which 4 of 19 (21.1%) survived to hospital discharge. Of those with at least 1 positive
examination finding, 13 of 30 subjects (43.3%) survived to hospital discharge. Subgroup
analysis showed that 9 of the 19 patients with absence of brainstem reflexes did not
have evidence of active neuromuscular blockade at the time of the examination; 2 of
9 (22.1%) survived to hospital discharge. Eight of these subjects in this group had
not received any prior sedation; 1 of 8 (12.5%) survived to hospital discharge. Only
1 of the 17 subjects who survived was discharged with poor neurologic function with
a CPC score = 3, whereas all others who survived had good neurologic function, CPC score = 1.
Conclusion
In this cohort of patients treated in a comprehensive postarrest care pathway that
included TH, absence of neurologic function on initial ED presentation was not reliable
for prognostication. Given these findings, clinicians should refrain from using the
initial ED neurological examination to guide the aggressiveness of care or in counseling
of family members regarding anticipated outcome.
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Article Info
Publication History
Published online: February 20, 2016
Accepted:
February 9,
2016
Received in revised form:
February 8,
2016
Received:
September 10,
2015
Identification
Copyright
© 2016 Elsevier Inc. All rights reserved.
