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Stuart Lane on prognostication post out of hospital cardiac arrest

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Always controversial, always entertaining, the fearsome but loveable Geordie Stuart Lane gives an excellent summary of a core ICU topic: managing out of hospital cardiac arrests. Nearly at the end of the BCC3 series - and in only a month we're doing it all again, this time in tropical Cairns - come and join us.

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Stuart Lane on prognostication post out of hospital cardiac arrest

  1. 1. Prognostication after OOHCA Stuart Lane
  2. 2. Background • Outcomes from cardiac arrest are poor • Usually significant neurological sequalae if the patient survives • Prognostication is difficult • It is a core business for ICM • An obsession with 72 hours being the time to prognosticate
  3. 3. What are the useful parameters? • Absent pupillary light or corneal reflex at 72 hours • Extensor or no response to central painful stimuli at 72 hours • Myoclonic status epilepticus (MSE) • Bilateral absent cortical responses on Somatosensory evoked potentials at 72 hours • Serum neuron-specific enolase > 33µgl-1
  4. 4. Pupil & corneal reflexes at 72hrs • Very rarely completely absent unless patient – Brain dead – Not officially brain dead – Obviously a poor prognosis • Levy JAMA 1985 – Almost 30 years old • These parameters predated the widespread use of therapeutic hypothermia
  5. 5. Extensor or no response to central painful stimuli at 72 hours • GCS not validated outside TBI • Huge variation in clinicians interpretation of GCS motor score – The GCS, especially motor score is done very badly in the CICM fellowship exam • Significant proportion of patients with m=2 whose outcome is not poor • Use of long-acting sedatives when renal function has been impaired and TH been used • Remi and propofol better?
  6. 6. Myoclonic status epilepticus (MSE) • MSE after a circulatory arrest on day 1 is a poor prognostic sign • Seen less frequently due to TH and paralysis • What about the Lance-Adams Sydrome? • Was actually cardiac arrest and airway obstruction • Evidence that hypoxia is not so bad as ischaemia and hypoxia • Usually is intention myoclonus after 48 hours • The history usually gives the story • Overdiagnosis if outlook is poor is bad • Underdiagnosis if outlook is good is bad • History and clinical examination
  7. 7. SSEP’s • Bilateral absence of the N20 component of the SSEP with median nerve stimulation recorded on days 1 to 3 or later after CPR accurately predicts a poor outcome. • Not usually available at many institutions • Timing is unclear • Not usually completely absent • EEG’s fare worse • Are more affected by drugs / metabolism • Burst suppression or generalised epileptiform activity are poor prognostic signs • Little accuracy
  8. 8. Serum neuron-specific enolase > 33µgl-1 • Levels quoted are before the advent of TH • TH can lower the NSE level compared to non-TH patients in OOHCA • Does this just demonstrate decreased neuronal injury because of TH • Needs validation
  9. 9. Others • Neuroimaging not helpful • But we do this all the time • For families? • For primary teams? • Circumstances of CPR • Witnessed • Bystander CPR • VF/VT arrest • Early defibrillation • ‘down-time’ / ROSC
  10. 10. Confounding factors • Multi-organ injury, both initial and reperfusion • Major metabolic derangement • Multiple sedative agents • Therapeutic hypothermia • Family dynamics
  11. 11. Thoughts • The context of the patient has been lost • These parameters are guidelines for patients • What is the patients background? • What is a good outcome for them? • Should not come to ICU? • But they often do • ‘They will have a good outcome because they had PPCI and TH’ • ‘It may not be as bad’
  12. 12. Thoughts • The basics should not be forgotten – Good history and examination – Open and honest discussion with the family • If there is really a risk of unacceptable badness, is this what they would want? • Do not use a single parameter to give you the answer – Obsession with motor score at 72 hours
  13. 13. Finally • The greatest ally of the physician is time • If a patient requires it, then let them have it. • If they don’t then don’t prolong it • Families are ordinary people in extraordinary circumstances • They need our guidance and direction • Not our academic debate and confusion • You can withdraw treatment on day 1 • But it may require longer to reach that conclusion

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