title: Clinical examination for prognostication in comatose cardiac arrest patients.
abstract: OBJECTIVE
  To build new algorithms for prognostication of comatose cardiac arrest patients using clinical examination, and investigate whether therapeutic hypothermia influences the value of the clinical examination.
  
  
  METHODS
  From 2000 to 2007, 500 consecutive patients in non-traumatic coma were prospectively enrolled, 200 of whom were post-cardiac arrest. Outcome was determined by modified Rankin Scale (mRS) score at 6 months, with mRS≤3 indicating good outcome. The clinical examination was performed on days 0, 1, 3 and 7 post-arrest, and clinical variables analyzed for importance in prognostication of outcome. A classification and regression tree analysis (CART) was used to develop a predictive algorithm.
  
  
  RESULTS
  Good outcome was achieved in 9.9% of patients. In CART analysis, motor response was often chosen as a root node, and spontaneous eye movements, pupillary reflexes, eye opening and corneal reflexes were often chosen as splitting nodes. Over 8% of patients with absent or extensor motor response on day 3 achieved a good outcome, as did 2 patients with myoclonic status epilepticus. The odds of achieving a good outcome were lower in patients who suffered asystole (OR 0.187, 95% CI: 0.039-0.875, p=0.033) compared with ventricular fibrillation or non-perfusing ventricular tachycardia, but some still achieved good outcome. The absence of pupillary and corneal reflexes on day 3 remained highly reliable for predicting poor outcome, regardless of therapeutic hypothermia utilization.
  
  
  CONCLUSIONS
  The clinical examination remains central to prognostication in comatose cardiac arrest patients in the modern area. Future studies should incorporate the clinical examination along with modern technology for accurate prognostication.
authors: Department of Neurology, Yale University School of Medicine, New Haven, CT, United States; Department of Neurology, Massachusetts General Hospital, Boston, MA, United States. Electronic address: david.greer@yale.edu.
authors: David M
authors: DM
authors: Greer
authors: Jingyun
authors: J
authors: Yang
authors: Patricia D
authors: PD
authors: Scripko
authors: John R
authors: JR
authors: Sims
authors: Sydney
authors: S
authors: Cash
authors: Ona
authors: O
authors: Wu
authors: Jason P
authors: JP
authors: Hafler
authors: David A
authors: DA
authors: Schoenfeld
authors: Karen L
authors: KL
authors: Furie
mesh_terms: D000465:Algorithms; D003128:Coma / Q000503:physiopathology* / Q000628:therapy; D015897:Comorbidity; D005260:Female; D006323:Heart Arrest / Q000503:physiopathology* / Q000628:therapy*; D006801:Humans; D007036:Hypothermia, Induced; D008297:Male; D008875:Middle Aged; D010808:Physical Examination; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D016896:Treatment Outcome
keywords: Cardiac arrest; Coma; Neurologic examination; Outcome; Prognosis
references: N Engl J Med. 2002 Feb 21;346(8):557-63
references: 11856794
references: Crit Care Resusc. 2009 Mar;11(1):39-41
references: 19281443
references: Ann Intern Med. 1981 Mar;94(3):293-301
references: 7224376
references: Contemp Neurol Ser. 1972;10:1-286
references: 4664014
references: Neurology. 2009 Feb 24;72(8):744-9
references: 19237704
references: Neurology. 2006 Jul 25;67(2):203-10
references: 16864809
references: Ann Neurol. 1995 Oct;38(4):697-8
references: 7574474
references: J Neurol. 1997 Sep;244(9):556-61
references: 9352452
references: N Engl J Med. 2002 Feb 21;346(8):549-56
references: 11856793
references: JAMA. 2004 Feb 18;291(7):870-9
references: 14970067
references: Neurology. 2006 Jan 10;66(1):62-8
references: 16401847
references: Circulation. 2010 Nov 2;122(18 Suppl 3):S768-86
references: 20956225
references: Ann Neurol. 2010 Mar;67(3):301-7
references: 20373341
references: Stroke. 2011 Apr;42(4):985-92
references: 21330629
references: BMC Cardiovasc Disord. 2011 Aug 08;11:48
references: 21824428
references: Radiology. 2009 Jul;252(1):173-81
references: 19420318
references: Crit Care Med. 2012 Apr;40(4):1150-6
references: 22020245
references: Neurocrit Care. 2011 Feb;14(1):61-7
references: 20931362
references: Neurology. 2008 Nov 4;71(19):1535-7
references: 18981375
references: Semin Neurol. 2013 Apr;33(2):157-66
references: 23888399
references: Circulation. 2010 Oct 19;122(16 Suppl 2):S345-421
references: 20956256
references: Ann Neurol. 2012 Feb;71(2):206-12
references: 22367993
references: JAMA. 1985 Mar 8;253(10):1420-6
references: 3968772
references: Clin Infect Dis. 2007 Feb 1;44(3):357-63
references: 17205441
references: Ann Neurol. 2010 Dec;68(6):907-14
references: 21061401
references: NeuroRehabilitation. 2010;26(1):5-13
references: 20130351
references: J Neurol Neurosurg Psychiatry. 1991 Dec;54(12):1044-54
references: 1783914
references: Resuscitation. 2013 Jun;84(6):e81-2
references: 23454437
references: Cancer. 2006 Jul 1;107(1):193-200
references: 16615102
references: Resuscitation. 1998 Feb;36(2):111-22
references: 9571727
references: J Neurol Neurosurg Psychiatry. 1998 Feb;64(2):267-8
references: 9489546