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Reply to Letter: "Outcome prediction in postanoxic coma with electroencephalography: the sooner the better"
No full textThe prerequisite for starting the prognostication process is the absence of consciousness assessed using clinical examination, which is usually not reliable before 72h or more from ROSC. The majority of patients destined to a good outcome will awake within 72h-96h from cardiac arrest. Consequently, prognostication is appropriate in patients who remain comatose after that time point. Results of predictors evaluated earlier should be considered only after a reliable clinical examination can be made.
When assessing prognosis, we recommended that the most robust predictors should be used first. These include the absence of either ocular reflexes (pupillary light response and corneal reflex) or the N20 wave of short-latency somatosensory evoked potentials (SSEPs). These predictors have given consistent results in more than five independent studies and have high precision (95%CI for false positive rate below 5%). Unfortunately, the current evidence supporting the use of EEG as a predictor of poor outcome is much less robust. In particular, predictors based on electrophysiology are often inaccurate during the first 24-48h after ROSC, mainly because of interference from both low body temperature and drugs used to maintain it. Even SSEPs, which are considered to be more resistant than EEG to these confounders, may give falsely pessimistic predictions when recorded during hypothermia treatment
EEG for prognostication in postanoxic coma: what you predict depends on when you predict
Full text linkCurrent protocols of targeted temperature management (TTM) for neuroprotection in resuscitated comatose patients require sedation and often paralysis in order to maintain consistent and low body temperatures during the frst 24-48 hours after return of spontaneous circulation as a result, predictors based on clinical examination are usually unreliable in the early postresuscitation phase,while predictors based on electrophysiology, namely short-latency somatosensory evoked potentials (SSEPs) and electroencephalogram (EEG) have been becoming increasingly popular after the advent of TTM.
Recent studies show that the prdictive value of EEG changes according to the timing after arrest: while an early EEG (within 12-24h) is more suitable to predict good neurological outcome, an EEG recorded later (24-72h) is more accurate for predicting poor neurological outcome
ERC 2010 guidelines for adult and pediatric resuscitation: summary of major changes
Full text linkThe new European Resuscitation Council (ERC) guidelines for cardiopulmonary resuscitation (CPR) published on October 18th, 2010, replace those published in 2005 and are based on the latest International Consensus on CPR Science with Treatment Recommendations (CoSTR). For both adult and pediatric resuscitation, the most important general changes include: the introduction of chest compression-only CPR in primary cardiac arrest as an option for rescuers who are unable or unwilling to perform expired-air ventilation; increased emphasis on uninterrupted, good-quality CPR and minimisation of both pre- and post-shock pauses during defibrillation. For adult resuscitation, the recommended chest compression depth and rate are 5-6 cm and 100-120 compressions per minute, respectively. Both a specific period of CPR before defibrillation during out-of-hospital resuscitation and use of endotracheal route for drug delivery during advanced life support are no longer recommended. During postresuscitation care, inspired oxygen should be titrated to obtain an arterial oxygen saturation of 94-98%, to avoid possible damage from hyperoxemia. In pediatric resuscitation, the role of pulse palpation for the diagnosis of cardiac arrest has been de-emphasised. The compression-to-ventilation ratio depends on the number of rescuers available, and a 30:2 ratio is acceptable even for rescuers with a duty to respond if they are alone. Chest compression depth should be at least 1/3 of the anterior-posterior chest diameter. The use of automated external defibrillators for children under one year of age should be considered
Neurologically Favorable Outcome Is Still Possible Despite Myoclonus in Comatose Survivors of Cardiac Arrest
No full textBased on the findings of our review, the latest European Resuscitation Council and European Society of Intensive Care Medicine (ERC-ESICM) guidelines recommend that myoclonus should be used only in combination with other criteria to predict poor neurological outcome after cardiac arrest.
A special reason for caution when using myoclonus as a predictor of poor outcome is the heterogeneity of its clinical manifestations, which may range from isolated, focal myoclonic jerks to a generalized, continuous and prolonged myoclonus, commonly described as ‘myoclonus status epilepticus’ or ‘status myoclonus". Results of earlier studies suggested that in patients resuscitated from cardiac arrest the prognosis of status myoclonus is consistently poor, while late-onset action myoclonus, also known as Lance-Adams syndrome, is often compatible with neurological recovery. Unfortunately, the study from Seder et al could not assess the prognosis of these different forms of myoclonus separately, since timing, persistence, and location of myoclonus were not recorded
Neurological prognostication after cardiac arrest
Full text linkPurpose of review
Prediction of neurological prognosis in patients who are comatose after successful resuscitation from
cardiac arrest remains difficult. Previous guidelines recommended ocular reflexes, somatosensory evoked
potentials and serum biomarkers for predicting poor outcome within 72 h from cardiac arrest. However,
these guidelines were based on patients not treated with targeted temperature management and did not
appropriately address important biases in literature.
Recent findings
Recent evidence reviews detected important limitations in prognostication studies, such as low precision
and, most importantly, lack of blinding, which may have caused a self-fulfilling prophecy and
overestimated the specificity of index tests. Maintenance of targeted temperature using sedatives and
muscle relaxants may interfere with clinical examination, making assessment of neurological status before
72 h or more after cardiac arrest unreliable.
Summary
No index predicts poor neurological outcome after cardiac arrest with absolute certainty. Prognostic
evaluation should start not earlier than 72 h after ROSC and only after major confounders have been
excluded so that reliable clinical examination can be made. Multimodality appears to be the most
reasonable approach for prognostication after cardiac arrest
Out-of-hospital cardiac arrest from neurologic cause: recognition and outcome*
No full textIn a minority of cases, neurologic injury precedes and causes cardiac arrest (CA). This occurs when CA is due to a neurologic cause—usually, a neurovascular accident, such as ischemic stroke, subarachnoid hemorrhage (SAH), or intracerebral hemorrhage.
The pathophysiology and clinical course of CA due to neurologic causes are much less studied than those of CA due to primary cardiac or respiratory causes, partly because of its less common occurrence and partly because these cases are often overlooked. In fact, during CA, neurological examination is of limited value and there is often little information on preceding symptoms. Furthermore, acute cerebrovascular events may induce electrocardiogram (ECG) changes, such as ST elevation, which mimic those of acute coronary syndromes
Neuroprognostication after cardiac arrest in Europe: new timings and standards
No full textDespite recent improvement in post-resuscitation care, about 50% of patients resuscitated from cardiac arrest die or have poorneurological prognosis.1Severe neurological damage due to post-anoxic brain injury is common after cardiac arrest and is a majorcause of post-resuscitation mortality. Early prognostication isimportant in patients who are comatose after resuscitation from cardiac arrest because inappropriate treatment in patients with nochance of a good neurological recovery can be avoided and relativescan be provided with correct information
A nuanced view of post-anoxic myoclonus
No full textMyoclonus after resuscitation from cardiac arrest is widelyviewed as an ominous finding. Based on this and several similar reports, the2006 guidelines from the American Academy of Neurology rec-ommended that the finding of early post-anoxic myoclonus wassufficient in isolation to accurately predict poor outcome andinform withdrawal of life-sustaining therapy. Subsequent evidence-based guidelineshave tempered this strong recommendation, making clear thatthe presence of myoclonus after cardiac arrest does not precludefavorable outcome A nuanced and precise understanding of post-anoxic myoclonusmay be hampered by complex taxonomy and clinical heterogene-ity. Terms like “myoclonus,” “status myoclonus” and “myoclonicstatus epilepticus” are used interchangeably in the literaturewithout consistent definitions. Early post-anoxic myoclonus should prompt EEG monitoring, not limitationor withdrawal of life-sustaining therapy
End-tidal CO2 to detect recovery of spontaneous circulation during cardiopulmonary resuscitation: We are not ready yet
No full textMeasurement of end-tidal carbon dioxide (ETCO2) is an established method for monitoring circulation during CPR. ETCO2 values depend on cardiac output and blood flow through venous return to the right side of the heart and therefore reflect CPR quality and predict resuscitation success. A clinical trial9 and a prospective cohort study showed that an ETCO2 value of 10 mmHg during out-of-hospital ALS accurately discriminated between survivors and non-survivors to hospital admission. In a study from Pokorna et al ROSC was associated with a sudden and sustained increase of ETCO2 ≥ 10 mmHg. The latest ALS Guidelines from the European Resuscitation Council5 suggested using an increase in ETCO2 to detect ROSC during CPR. However, the relevant evidence in support is still limited
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