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Practice Parameter: Outcome in Comatose Survivors of Cardiopulmonary Resuscitation

A recent practice parameter from the American Academy of Neurology, and a second article reporting the practical experience of neurologists who implemented similar practices

The American Academy of Neurology (AAN) has published a valuable new practice parameter for prediction of poor outcome in comatose adult survivors of cardiopulmonary resuscitation (CPR). This is a comprehensive, evidence-based review of the prognostic value of such factors as the circumstances surrounding the CPR, the clinical examination, and ancillary investigations (electrophysiologic, biochemical, and radiologic). The authors use well-regarded standards to review, grade (A through C, and unknown), and analyze this evidence.

The review identified the following features as aiding prediction of poor outcome in comatose survivors of CPR:

• bilateral absence of pupillary light responses and corneal reflexes during days 1 to 3 after CPR (level A),
  
• only extensor responses or no motor responses to pain after 3 days (level B),
  
• myoclonic status epilepticus at day 1 (level B),
  
• bilaterally absent N20 median nerve somatosensory evoked potentials (SSEP) at 1 to 3 days (level B), and
  
• elevated serum neuron-specific enolase level >33 µg/L at 1 to 3 days (level B).
  

A related study implies that neurologists use such information, particularly the results of ancillary tests, in decisions about withdrawal of life support. Geocadin and colleagues prospectively evaluated data from 58 comatose CPR survivors referred for neurologic consultation at one hospital. The authors demonstrate that the results of cortical evoked potential testing (specifically in the form of SSEP testing) correlated best with waiting time to withdrawal of life-sustaining therapies. For instance, among the 40 patients whose life support was eventually withdrawn, the median waiting time was 7 days for patients with preserved SSEPs and only 1 day in patients with bilaterally absent N20 SSEP components.

Comment: Neurologic outcome is well recognized as the major cause of poor outcomes in comatose CPR survivors. Proper management and decisions about withdrawal of life-sustaining measures for such patients require neurologists to determine the prognosis for recovery of neurologic function and to effectively communicate this determination to decision-making family and medical staff. In this regard, these two articles provide valuable information. The practice parameter identifies the clinical findings and diagnostic tests that reliably predict poor outcome within the first few days after cardiac arrest. In addition, the authors make a thoughtful effort, using expert opinion, to provide practical guidelines for neurologists and other physicians for advising and guiding family decision makers in a humane, moral, and ethical manner. The Geocadin study demonstrates that such prognostic information, particularly ancillary tests, influences neurologists’ recommendations about withdrawal of life support.

— Allan Krumholz, MD

Dr. Krumholz is Professor of Neurology, University of Maryland School of Medicine, and Director, Maryland Epilepsy Center, University of Maryland Medical Center, Baltimore.

Published in Journal Watch Neurology October 17, 2006

Citation(s):

Wijdicks EFM et al. 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 Jul 25; 67:203-10.

• Original article (Subscription may be required)
• Medline abstract (Free)

Geocadin RG et al. Neurologic prognosis and withdrawal of life support after resuscitation from cardiac arrest. Neurology 2006 Jul 11; 67:105-8.

• Original article (Subscription may be required)
• Medline abstract (Free)