limited by a small number of patients in some cells, so that there is still a substantial range to the 95% confidence interval.
A second finding is that a handful of easily obtained clinical findings on examination can carry considerable weight. For example, loss of one of the most basic brain stem reflexes— pupillary response—noted on initial exam was associated with no recovery or a vegetative state in 94% of patients, and no patient had a good or moderate recovery. At day 3, withdrawal to stimuli and spontaneous eye movements was associated with many patients with either good or very poor outcome. An attempt to speak within the first few days, even limited to incomprehensible moaning, has been reported to be a good prognostic sign, although present in only a small number of patients (17,20).
The Glasgow Coma Scale (GCS) ( Table 1) utilizes some of the same clinical signs of eye opening and motor response but with an additional feature of verbal response. [Best verbal response was not found to be a useful factor in the Levy study (20).] A Belgian study of 360 patients resuscitated from out-of-hospital CA found good outcome predicted by a GCS of > 10 and poor outcome predicted by a GCS of < 4 (21). In a validation study, they found that these criteria had a sensitivity of 96%, a specificity of 86%, a negative predictive value of 97%, and a positive predictive value of only 77%. A more recent study by the Brain Resuscitation Clinical Trials Study Group supported these findings (22). An analysis of outcome in 262 patients in coma following CA revealed that the most useful predictors were (i) absence of papillary light reaction at baseline predicted poor outcome, (ii) absence of motor response to painful stimuli on day 3 predicted poor outcome, and (iii) use of the Glasgow or Glasgow-Pittsburgh coma scale was no better than use of some of its components.
Table 1 Glasgow Coma Scale
3—to verbal command
1—no response Best motor response
6—obeys verbal command
5—localizes to pain
1—no response Best verbal response
5—oriented and converses
4—disoriented and converses
2—incomprehensible sounds 1—no response
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