This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Contact me when this article is cited  Related Content  • Related letters  • Similar articles in JAMA  Topic Collections  • Neurology  • Coma/ Vegetative State  • Patient-Physician Relationship/ Care  • End-of-life Care/ Palliative Medicine  • Prognosis/ Outcomes  • The Rational Clinical Examination  • Alert me on articles by topic  Social Bookmarking   What's this?

Assessing Outcome for Comatose Survivors of Cardiac Arrest

Christopher M. Booth, MD; Robert H. Boone, MD, MSc; George Tomlinson, PhD; Allan S. Detsky, MD, PhD, FRCPC

JAMA. 2004;291:870-879.

Context  Most survivors of cardiac arrest are comatose after resuscitation, and meaningful neurological recovery occurs in a small proportion of cases. Treatment can be lengthy, expensive, and often difficult for families and caregivers. Physical examination is potentially useful in this clinical scenario, and the information obtained may help physicians and families make accurate decisions about treatment and/or withdrawal of care.

Objective  To determine the precision and accuracy of the clinical examination in predicting poor outcome in post–cardiac arrest coma.

Data Sources and Study Selection  We searched MEDLINE for English-language articles (1966-2003) using the terms coma, cardiac arrest, prognosis, physical examination, sensitivity and specificity, and observer variation. Other sources came from bibliographies of retrieved articles and physical examination textbooks. Studies were included if they assessed the precision and accuracy of the clinical examination in prognosis of post–cardiac arrest coma in adults. Eleven studies, involving 1914 patients, met our inclusion criteria.

Data Extraction  Two authors independently reviewed each study to determine eligibility, abstract data, and classify methodological quality using predetermined criteria. Disagreement was resolved by consensus.

Data Synthesis  Summary likelihood ratios (LRs) were calculated from random effects models. Five clinical signs were found to strongly predict death or poor neurological outcome: absent corneal reflexes at 24 hours (LR, 12.9; 95% confidence interval [CI], 2.0-68.7), absent pupillary response at 24 hours (LR, 10.2; 95% CI, 1.8-48.6), absent withdrawal response to pain at 24 hours (LR, 4.7; 95% CI, 2.2-9.8), no motor response at 24 hours (LR, 4.9; 95% CI, 1.6-13.0), and no motor response at 72 hours (LR, 9.2; 95% CI, 2.1-49.4). The proportion of individuals' dying or having a poor neurological outcome was calculated by pooling the outcome data from the 11 studies (n = 1914) and used as an estimate of the pretest probability of poor outcome. The random effects estimate of poor outcome was 77% (95% CI, 72%-80%). The highest LR increases the pretest probability of 77% to a posttest probability of 97% (95% CI, 87%-100%). No clinical findings were found to have LRs that strongly predicted good neurological outcome.

Conclusions  Simple physical examination maneuvers strongly predict death or poor outcome in comatose survivors of cardiac arrest. The most useful signs occur at 24 hours after cardiac arrest, and earlier prognosis should not be made by clinical examination alone. These data provide prognostic information, rather than treatment recommendations, which must be made on an individual basis incorporating many other variables.

Author Affiliations: Departments of Medicine (Drs Booth, Boone, Tomlinson, and Detsky), and Health Policy Management and Evaluation (Dr Detsky), University of Toronto, and Department of Medicine, Mount Sinai Hospital (Drs Tomlinson and Detsky) and University Health Network (Drs Tomlinson and Detsky), Toronto, Ontario.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati     What's this?

RELATED LETTERS

Usefulness of the Glasgow Coma Score in Survivors of Cardiac Arrest
Zsolt T. Stockinger
JAMA. 2004;291(19):2313.
EXTRACT | FULL TEXT  

Usefulness of the Glasgow Coma Score in Survivors of Cardiac Arrest—Reply
Christopher M. Booth and Allan Detsky
JAMA. 2004;291(19):2313.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Predictors of awakening from postanoxic status epilepticus after therapeutic hypothermia
Rossetti et al.
Neurology 2009;72:744-749.
ABSTRACT | FULL TEXT  

Post-Cardiac Arrest Syndrome: Epidemiology, Pathophysiology, Treatment, and Prognostication A Consensus Statement From the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council
Neumar et al.
Circulation 2008;118:2452-2483.
FULL TEXT  

Left Ventricular Systolic Function and Outcome After In-Hospital Cardiac Arrest
Gonzalez et al.
Circulation 2008;117:1864-1872.
ABSTRACT | FULL TEXT  

Abnormal response of the extremities to pain stimulation immediately after the return of spontaneous circulation from cardiopulmonary arrest
Yanagawa et al.
Emerg. Med. J. 2008;25:19-22.
ABSTRACT | FULL TEXT  

Prediction of cognitive dysfunction after resuscitation from out-of-hospital cardiac arrest using serum neuron-specific enolase and protein S-100
Grubb et al.
Heart 2007;93:1268-1273.
ABSTRACT | FULL TEXT  

Status epilepticus: An independent outcome predictor after cerebral anoxia
Rossetti et al.
Neurology 2007;69:255-260.
ABSTRACT | FULL TEXT  

Brain Injury After Cardiopulmonary Arrest and Its Assessment With Diffusion-Weighted Magnetic Resonance Imaging
Barrett et al.
Mayo Clin Proc. 2007;82:828-835.
ABSTRACT | FULL TEXT  

Predicting survival with good neurologic recovery at hospital admission after successful resuscitation of out-of-hospital cardiac arrest: the OHCA score
Sunde et al.
Eur Heart J 2007;28:773-773.
FULL TEXT  

Will he ever be conscious again?
Hijdra
Eur Heart J 2007;28:1-2.
FULL TEXT  

Prediction of neurological outcome after cardiopulmonary resuscitation by serial determination of serum neuron-specific enolase
Reisinger et al.
Eur Heart J 2007;28:52-58.
ABSTRACT | FULL TEXT  

Predicting survival with good neurological recovery at hospital admission after successful resuscitation of out-of-hospital cardiac arrest: the OHCA score
Adrie et al.
Eur Heart J 2006;27:2840-2845.
ABSTRACT | FULL TEXT  

Higher Survival Rates Among Younger Patients After Pediatric Intensive Care Unit Cardiac Arrests
Meaney et al.
Pediatrics 2006;118:2424-2433.
ABSTRACT | FULL TEXT  

Neurologic prognosis and withdrawal of life support after resuscitation from cardiac arrest.
Geocadin et al.
Neurology 2006;67:105-108.
ABSTRACT | FULL TEXT  

Timely Referral of Potential Organ Donors
Ehrle
Crit Care Nurse 2006;26:88-93.
FULL TEXT  

Severe brain injury to neurological determination of death: Canadian forum recommendations.
Shemie et al.
CMAJ 2006;174:S1-13.
FULL TEXT  

De l'atteinte cerebrale grave au diagnostic de deces neurologique : recommendations issues du Forum canadien
Shemie et al.
CMAJ 2006;174:SF1-SF13.
FULL TEXT  

Cardiopulmonary resuscitation in continuing care settings: time for a rethink?
Conroy et al.
BMJ 2006;332:479-482.
FULL TEXT  

Prediction of poor outcome within the first 3 days of postanoxic coma
Zandbergen et al.
Neurology 2006;66:62-68.
ABSTRACT | FULL TEXT  

First Documented Rhythm and Clinical Outcome From In-Hospital Cardiac Arrest Among Children and Adults
Nadkarni et al.
JAMA 2006;295:50-57.
ABSTRACT | FULL TEXT  

Part 2: Ethical Issues
Circulation 2005;112:IV-6-IV-11.
FULL TEXT  

Part 7.5: Postresuscitation Support
Circulation 2005;112:IV-84-IV-88.
FULL TEXT  

Early prediction of individual outcome following cardiopulmonary resuscitation: systematic review
Kaye
Emerg. Med. J. 2005;22:700-705.
ABSTRACT | FULL TEXT  

Case 26-2005 - A 48-Year-Old Man with Sudden Loss of Consciousness while Jogging
Binder et al.
NEJM 2005;353:824-832.
FULL TEXT  

Prognosis and Decision Making in Severe Stroke
G. Holloway et al.
JAMA 2005;294:725-733.
ABSTRACT | FULL TEXT  

Early Detection of Global Cerebral Anoxia: Improved Accuracy by High-b-Value Diffusion-Weighted Imaging with Long Echo Time
Tha et al.
Am. J. Neuroradiol. 2005;26:1487-1497.
ABSTRACT | FULL TEXT  

ADDITIONAL ARTICLES ABSTRACTED IN ACP JOURNAL CLUB
Evid. Based Med. 2004;9:131-131.
FULL TEXT  

Usefulness of the Glasgow Coma Score in Survivors of Cardiac Arrest
Stockinger
JAMA 2004;291:2313-2313.
FULL TEXT