Plum and posner’s diagnosis of stupor and coma fourth Edition series editor sid Gilman, md, frcp

CARDIOPULMONARY ARREST/

HYPOXIC-ISCHEMIC

ENCEPHALOPATHY

Several large studies have examined outcome

in coma specifically following cardiac arrest.

Data from 942 patients prospectively enrolled

in the Brain Resuscitation Clinical Trials

35

(circa 1979 to 1994) demonstrated that loss of

any of the cranial nerve reflexes following car-

diac arrest significantly predicted poor out-

come. Booth and associates

2

reviewed all avail-

able large studies of coma following cardiac

arrest from 1966 to 2003 to assess the precision

and accuracy of the physical examination in

prognosis. They found that five clinical signs

were strongly predictive of death, VS, or severe

disability (GOS 1, 2, or 3): absent corneal re-

flexes, absent pupillary reflexes, absent with-

drawal to painful stimuli, absent motor re-

sponse at 24 hours, and absent motor response

at 72 hours. Notably, no clinical examination

finding strongly predicted a GOS of 4 or 5. In

the aggregate, the data shown in Table 9–8

support the algorithms shown in Figure 9–3

and add further details as well as time points. It

should be recognized that the Booth et al. pre-

dictors aggregate severely disabled outcomes

(GOS 3) with outcomes of death or permanent

VS (GOS 1 and 2). Thus, careful explanation

of the predicted outcomes is required if the

physician uses these data to counsel families, as

choices concerning severe disability may differ

widely (see family dynamics and philosophic

considerations, page 379).

ELECTROPHYSIOLOGIC TESTING

IN HYPOXIC-ISCHEMIC

ENCEPHALOPATHY

Although the physical examination gives a

strong prediction of poor outcome, it does not

accurately assess the extent of cortical injury.

Electrophysiologic testing adds valuable data.

SSEPs provide the best predictors of poor

Table 9–7 Two-Week Outcome of Nontraumatic Coma and

Coma Etiology

Two-Week Outcome

Coma Etiology

No. (%)

% Awake

% Dead

% Coma

Hypoxic/ischemic

61 (36.1)

21.3

54.1

24.6

Metabolic or septic

37 (21.8)

32.4

48.7

18.9

Focal cerebral injury

38 (22.5)

34.2

47.4

18.4

Generalized cerebral injury

22 (13.0)

45.4

36.4

18.2

Drug induced

11 (6.5)

72.7

0

27.3

All

169 (100)

33.1

44.4

21.5

Modified from Sacco et al.,

34

with permission.

Table 9–6 Variables Correlated With Two-Month Mortality

Two-Month Mortality, Number (%)

Risk Factor Present

on Day Three

If Factor Present

If Factor

Not Present

Abnormal brainstem function

88/99 (89)

83/136 (61)

Absent verbal response

151/175 (86)

23/57 (40)

Absent withdrawal to pain

122/136 (90)

52/96 (54)

Creatinine !132.6 mmol/L

(1.5 mg/dL)

82/94 (87)

99/153 (65)

Age !70

93/111 (84)

88/136 (65)

From Hamel et al.,

33

with permission.

352

Plum and Posner’s Diagnosis of Stupor and Coma

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Table 9–8 Useful Clinical Findings in the Prognosis of

Postcardiac Arrest Coma Organized by Time After Onset

of Coma

LR* of Poor Neurologic Outcome

(95% Confidence Interval)

Clinical Finding

Positive

Negative

Absent pupillary reflex

7.2 (1.9–28.0)

0.5 (0.4–0.6)

Absent motor response

3.5 (1.4–8.6)

0.6 (0.4–0.7)

Absent corneal reflex

3.2 (1.1–9.5)

0.7 (0.6–0.8)

Absent oculocephalic reflex

2.5 (1.3–4.8)

0.4 (0.3–0.6)

Absent spontaneous eye movement

2.2 (1.3–4.0)

0.4 (0.3–0.6)

ICS <4

2.2 (1.1–4.5)

0.2 (0.1–0.6)

GCS <5

1.4 (1.1–1.6)

0.3 (0.2–0.5)

Absent verbal effort

1.2 (0.9–1.6)

0.1 (0.0–0.7)

At 12 Hours

Absent cough reflex

13.4 (4.4–40.3)

0.3 (0.2.-0.4)

Absent corneal reflex

9.1 (3.9–21.1)

0.3 (0.2–0.4)

Absent gag reflex

8.7 (4.0–18.9)

0.4 (0.4–0.5)

Absent pupillary reflex

4.0 (2.5–6.6)

0.5 (0.5–0.6)

GCS <5

3.5 (2.4–5.2)

0.4 (0.3–0.4)

Absent motor response

3.2 (2.2–4.6)

0.4 (0.3–0.5)

Absent withdrawal to pain

2.3 (1.9–3.1)

0.2 (0.1–0.2)

Absent verbal effort

1.6 (1.4–1.9)

0.1 (0.0–0.1)

At 24 Hours

Absent cough reflex

84.6 (5.3–1342.0)

0.4 (0.3–0.5)

Absent gag reflex

24.9 (6.3–98.3)

0.5 (0.4–0.5)

GCS <5

8.8 (5.1–15.1)

0.4 (0.3–0.4)

Absent eye opening to pain

5.9 (3.9–9.0)

0.3 (0.3–0.4)

Absent spontaneous eye movement

3.5 (1.4–8.8)

0.5 (0.4–0.7)

Absent eye opening to pain

3.0 (1.5–6.2)

0.4 (0.3–0.5)

Absent oculocephalic reflex

2.9 (1.8–4.6)

0.5 (0.5–0.6)

Absent spontaneous eye movement

2.7 (2.1–3.4)

0.3 (0.2–0.3)

Absent verbal effort

2.4 (2.0–2.9)

0.1 (0.0–0.1)

At 48 Hours

GCS <6

2.8 (1.3–5.9)

0.3 (0.1–0.5)

GCS <10

1.3 (1.0–1.7)

0.0 (0.0–0.7)

At 72 Hours

Absent withdrawal to pain

36.5 (2.3–569.9)

0.3 (0.2–0.4)

Absent spontaneous eye movement

11.5 (1.7–79.0)

0.6 (0.5–0.7)

Absent verbal effort

7.4 (2.0–28.0)

0.3 (0.2–0.5)

Absent eye opening to pain

6.9 (1.8–27.0)

0.5 (0.4–0.6)

At 7 Days

Absent withdrawal to pain

29.7 (1.9–466.0)

0.4 (0.3–0.6)

Absent verbal effort

14.1 (2.0–97.7)

0.4 (0.2–0.6)

GCS, Glasgow Coma Scale; ICS, Innsbruck Coma Scale; LR, likelihood ratio.

*Clinical findings that have a positive LR >2 and a lower confidence interval boundary >1 are

presented with the corresponding negative LR.

Modified from Booth et al.,

2

with permission.

353

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