Prognosis And Clinical Predictors

The neurologic examination is the first step in assessing the prognosis of a comatose patient after CA (17). "Coma" can be defined as a state of unarousable unresponsiveness characterized by the eyes being closed (as in sleep) and the absence of purposeful movements to stimulation (18). "Stupor" refers to a state of deep sleep, with arousal only to vigorous stimulation. In contrast, patients in vegetative states do not appear asleep but open their eyes to stimulation (although diurnal sleep-wake cycles may develop). This state of wakefulness, however, does not include evidence of cognition or awareness. Spontaneous movements might be observed on general observation of the patient, and determination should be made as to whether they are purposeful, semipurposeful (e.g., appropriate withdrawal from a noxious stimulus) or reflex movements. Some very unusual complex reflex movements have been reported even in brain-dead patients and should not be confused with purposeful motor activity (19).

The second step in assessment is determining the degree and duration of arousal (if any) to graded stimulation. One starts with verbal stimuli and then adds increasingly vigorous physical stimulation. Painful stimuli, however, such as sternal rub, pinching, or pinprick, can also elicit reflex responses, which may be difficult to distinguish from purposeful withdrawal. Low-level responses, such as triple flexion or decerebrate posturing are patterned and tend to repeat, regardless of the location or type of stimulus. Semipurposeful withdrawal movements, however, typically display movement of the body part away from the painful stimulus and will change depending upon the location of the stimulus.

A number of studies have attempted to derive rules that predict awakening from postanoxic coma. One of the most widely used studies derives from a series of 210 patients, seen at the Cornell Medical Center, who underwent serial neurologic examinations after being found in a comatose state after CA (20). Noteworthily, two-thirds of the patients in this study had their CA in the hospital. Outcome was determined at 1 year and graded by the following functional scale: (i) coma until death, (ii) vegetative state, (iii) severe disability but conscious, (iv) moderate disability (independent but unable to resume prior level of activity), and (v) good recovery (able to return to prior level of function). By day 3 after CA, 25 (12%) patients awoke from coma. Only 3 more awoke within the next 2 weeks. Of the 28 patients who awoke, 21 (75%) recovered independence. On the other hand, 86 (41%) patients died within the first 3 days, and 134 (64%) died within the first week. The clinical status of the remainder developed into vegetative state. Multivariate analysis with a recursive partitioning algorithm was used to identify portions of the neurologic examination that predicted outcome at 1 year.

The results are presented in (Fig. 1). A series of flow charts shows the actual outcome of patients depending upon key findings on neurologic examination at various time points from initial exam (within 24 hr to 2 weeks). Several important points are evident in the data. First, the certainty of outcome for either worst outcome or best outcome is better at 3 days than at baseline or day 1. Most physicians in clinical practice are uncomfortable with the unacceptably high error rate associated with prognostication prior to day 3. On the other hand, the data is

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