Post arrest neurologic prognostication

This, one of many reviews on the topic, though directed to neurologists, contains some points of interest to hospitalists.

Combined modalities of assessment are required. No single category by itself (eg physical exam, imaging, EEG, biomarkers) is enough.

Optimal timing of assessment is influenced by whether hypothermia was used and the anticipated washout times of any sedatives or paralytics. The review doesn't make a clear categorization in this regard the way, for example, the new ACLS guidelines do.

Adverse physical findings should be viewed in terms of their false positive rates for poor neurologic outcome. Examples follow.

Fixed pupils after 72 hours have a false positive rate of 0.5%, 95% CI 0-2.

Absent corneals after 72 hours have a false positive rate of 5%, CI 0-25.

Myoclonus must be interpreted in the context of the EEG and requires expertise.

Absent or extensor posturing to pain after 72 hours has a false positive rate of 10-24%, CI 6-48%

The use of EEG and imaging is complex and requires expertise.

The use of biomarkers is discussed. These are novel markers not available with rapid turnaround in many community hospitals.