title: ED prognostication of comatose cardiac arrest patients undergoing therapeutic hypothermia is unreliable.
abstract: BACKGROUND
  Therapeutic hypothermia (TH) improves patient survival with good neurologic outcome after cardiac arrest. The value of early clinician prognostication in the emergency department (ED) has not been studied in this patient population.
  
  
  OBJECTIVE
  To determine if physicians can accurately predict survival and neurologic outcome at hospital discharge of resuscitated, comatose out-of-hospital cardiac arrest (OHCA) patients treated in a post-cardiac arrest clinical pathway that included TH.
  
  
  METHODS
  This was a prospective, observational study conducted at a tertiary referral center. Participants were physicians involved in the resuscitation of OHCA patients treated with a clinical pathway that included TH. Immediately after patient resuscitation in the ED, physicians recorded their prediction of patient survival and neurologic outcome on a standardized questionnaire. Neurologic outcome was assessed by the cerebral performance category.
  
  
  RESULTS
  Forty-two physicians completed questionnaires on 17 patients enrolled from October 2009 to March 2010. Sensitivity and specificity of physician prediction of patient survival were 0.67 (95% confidence interval [CI], 0.45-0.83) and 0.82 (95% CI, 0.59-0.94), respectively, with an area under the curve of 0.74 (95% CI, 0.61-0.88), a positive likelihood ratio (+LR) of 3.72 (95% CI, 1.30-11.02), and a -LR of 0.40 (95% CI, 0.21-0.77). Sensitivity and specificity of physician prediction of good neurologic outcome were 0.40 (95% CI, 0.20-0.64) and 0.69 (95% CI, 0.50-0.84), respectively, with an area under the curve of 0.55 (95% CI, 0.39-0.70), a +LR of 1.29 (95% CI, 0.56-3.03), and a -LR of 0.87 (95% CI, 0.53-1.41).
  
  
  CONCLUSIONS
  Physicians poorly prognosticate both survival and neurologic outcome in comatose OHCA patients undergoing TH. Premature prognostication in the ED is unreliable and should be avoided.
authors: Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC. Electronic address: cathywares@gmail.com.
authors: Catherine M
authors: CM
authors: Wares
authors: Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC; Department of Internal Medicine, Division of Critical Care, Carolinas Medical Center, Charlotte, NC.
authors: Alan C
authors: AC
authors: Heffner
authors: Dickson Advanced Analytics Group, Carolinas Health Care System, Charlotte, NC.
authors: Shana L
authors: SL
authors: Ward
authors: Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
authors: David A
authors: DA
authors: Pearson
mesh_terms: D016887:Cardiopulmonary Resuscitation; D003128:Coma / Q000209:etiology / Q000628:therapy*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007036:Hypothermia, Induced / Q000379:methods*; D008297:Male; D008875:Middle Aged; D058687:Out-of-Hospital Cardiac Arrest / Q000150:complications / Q000628:therapy*; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D011795:Surveys and Questionnaires; D016019:Survival Analysis; D016896:Treatment Outcome