Advertisement

Early neurologic examination is not reliable for prognostication in post–cardiac arrest patients who undergo therapeutic hypothermia

Published:February 20, 2016DOI:https://doi.org/10.1016/j.ajem.2016.02.002

      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.
      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Guidelines CPR 2005
        2005 AHA guidelines for cardiopulmonary resuscitation and emergency cardiac care.
        Circulation. 2005; 112 ([5IV-84-IV-5.0])
        • Nolan J.P.
        • Neumar R.W.
        • Adrie C.
        • Abiki M.
        • Berg R.A.
        • Bbttiger B.W.
        • et al.
        Post–cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication.
        Resuscitation. 2008; 79: 350-379
        • The Hypothermia After Cardiac Arrest Study Group (HACA Study Group)
        Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest.
        N Engl J Med. 2002; 346: 549-556
        • Bernard S.A.
        • Gray T.W.
        • Buist M.D.
        • Jones B.M.
        • Silvester W.
        • Gutteridge G.
        • et al.
        Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.
        N Engl J Med. 2002; 346: 557-563
        • Nielsen N.
        • Wetterslev J.
        • Cronberg T.
        • Kjaergaard J.
        • Wise M.P.
        • Pellis T.
        • et al.
        Targeted temperature management at 33°C vs 36°C after cardiac arrest.
        N Engl J Med. 2013; 69: 2197-2206
        • Hemphill J.C.
        • White D.B.
        Clinical nihilism in neuro-emergencies.
        Emerg Med Clin North Am. 2009; 27: 27-37
        • Yannopoulos D.
        • Kotsifas K.
        • Aufderheide T.P.
        • Lurie K.G.
        Cardiac arrest, mild therapeutic hypothermia, and unanticipated cerebral recovery.
        Neurologist. 2007; 13: 369-375
        • Perman S.M.
        • Kirkpatrick J.N.
        • Reitsma A.M.
        • Gaieski D.F.
        Timing of neuroprognostication in postcardiac arrest therapeutic hypothermia.
        Crit Care Med. 2012; 40: 719-724
        • Becker K.J.
        • Baxter A.B.
        • Cohen W.A.
        • Bybee H.M.
        • Tirschwell D.L.
        • Newell D.W.
        • et al.
        Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies.
        Neurology. 2001; 56: 766-772
        • Hemphill J.C.
        Do-not-resuscitate orders, unintended consequences, and the ripple effect.
        Crit Care. 2007; 11: 121
        • Heffner A.C.
        • Pearson D.A.
        • Nussbaum M.L.
        • Jones A.E.
        Regionalization of post–cardiac arrest care: implementation of a cardiac resuscitation center.
        Am Heart J. 2012; 164: 493-501
        • Cummins R.O.
        • Chamberlain D.A.
        • Abramson N.S.
        • Allen M.
        • Baskett P.J.
        • Becker L.
        • et al.
        Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. A statement for health professionals from a Task Force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council.
        Circulation. 1991; 84: 960-975
        • Wijdicks E.F.
        • Hijdra A.
        • Young G.B.
        • Bassetti C.L.
        • Wiebe S.
        Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence based review): report of the quality standards subcommittee of the American Academy of Neurology.
        Neurology. 2006; 67: 203-210
        • Al Thenayan E.
        • Savard M.
        • Sharpe M.
        • Johnson M.M.
        • Divertie G.D.
        • Meschia J.F.
        Predictors of poor neurologic outcome after induced mild hypothermia following cardiac arrest.
        Neurology. 2008; 71: 1535-1537
        • Perman S.M.
        • Kirkpatrick J.N.
        • Reitsma A.M.
        • Gaieski D.F.
        • Lau B.
        • Smith T.M.
        • et al.
        Timing of neuroprognostication in postcardiac arrest therapeutic hypothermia.
        Crit Care Med. 2012; 40: 719-724
        • Albaeni A.
        • Chandra-Strobos N.
        • Vaidya D.
        • Eid Shaker M.
        Predictors of early care withdrawal following out-of-hospital cardiac arrest.
        Resuscitation. 2014; 85: 1455-1461
        • Stead L.G.
        • Wijdicks E.F.
        • Bhagra A.
        • Kashyap R.
        • Bellolio M.F.
        • Nash D.L.
        • et al.
        Validation of a new coma scale, the FOUR score, in the emergency department.
        Neurocrit Care. 2009; 10: 50-54
        • Jacobs I.
        • Nadkarni V.
        • Bahr J.
        • Berg R.A.
        • Billi J.E.
        • Borsaert L.
        • et al.
        Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa).
        Resuscitation. 2004; 63: 233-249