Sara Gray discusses the complex topic of prognostication post cardiac arrest in neuro intensive care. There is a short list of things that keep Sara up at night. She describes a specific cardiac arrest nightmare she has. She is looking after a patient post cardiac arrest. They remain in a coma after cooling. As they meet brain death criteria and they are an organ donor, they are transferred to the operating room. Whilst there, they regain spontaneous respirations. Although this is terrifying, these situations do happen! And cases like this defy all efforts at accurate prognostication in post cardiac arrest patients. Prognostication matters. It matters for the patient, their family and got judicious resource management. The trouble is, that varying guidelines around the world do not agree. In patients who have not been cooled, then you may start prognostication 72 hours post return of spontaneous circulation (ROSC). Before that time the brain may not have had adequate time to heal from the arrest and the clinical indicators may not be accurate. In the hypothermia group there is differing guidelines. Some guidelines suggest doing it the same way – prognostication after 72 hours. Others suggest 72 hours after achieving normothermia. This equates to 4.5 days. Why the difference? Different medicolegal environments may play a part. However, as Sara explains, some guidelines may be guided by concern over the emerging data about people who wake up late. Sara fears looking a family in the eye and telling them the patient won’t wake up and being wrong. Her advice is to wait 4.5 days. She then recommends starting with a subgroup of patients with a low motor score on GCS. From there you can use indicators with the best accuracy which are bilateral absence of pupillary response, corneal reflex, and somatosensory evoked potentials. Bilateral absence of all three equals a dire prognosis. For more like this, head to our podcast page. #CodaPodcast

1. Neuroprognostication after
cardiac arrest

9. 0 24 48 72 96 120
TTM
No TTM
Cooling TTM Rewarming Normothermia
ROSC

10. 0 24 48 72 96 120
TTM
No TTM
Cooling TTM Rewarming Normothermia
ROSC

11. Gold B et al. Resus 2014
N=89
OHCA, alive
69 woke
<48h
CPC 1 or 2
67 (97%)
10 woke
48-72h
CPC 1 or 2
10 (100%)
10 woke >
72h
CPC 1 or 2
8 (80%)

12. Wait 4.5 days

14. Wait enough time
Exclude cofounders
Comatose patients (M1 or M2)

15. Wait enough time
Exclude cofounders FP Rate
Comatose patients (M1 or M2) 0.21

16. Wait enough time
Exclude cofounders FP Rate
Comatose patients (M1 or M2) 0.21
1. Absent pupils
2. Absent corneals
3. Absent SSEP’s

17. Wait enough time
Exclude cofounders FP Rate
Comatose patients (M1 or M2) 0.21
1. Absent pupils 0.004
2. Absent corneals 0.02
3. Absent SSEP’s 0.007

18. Other options
• Myoclonic status epilepticus
• Unfavourable EEG
• Increased NSE
• Unfavourable imaging

19. Wait 4.5 days
Multi-modal
assessment

20. @EmICUcanada