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## Complete Summary

#### GUIDELINE TITLE

Practice parameter: prediction of outcome in comatose survivors after
cardiopulmonary resuscitation (an evidence-based review). Report of the
Quality Standards Subcommittee of the American Academy of Neurology.

#### BIBLIOGRAPHIC SOURCE(S)

Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S, Quality Standards
Subcommittee of the American Academy of Neurology. Practice parameter:
prediction of outcome in comatose survivors after cardiopulmonary
resuscitation (an evidence-based review): report of the Quality
Standards Subcommittee of the American Academy of Neurology.
Neurology 2006 Jul 25;67(2):203-10. \[71 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16864809)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Cardiac arrest

#### GUIDELINE CATEGORY

Evaluation\
Risk Assessment

#### CLINICAL SPECIALTY

Neurology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To systematically review outcomes in comatose survivors after cardiac
arrest and cardiopulmonary resuscitation (CPR)

#### TARGET POPULATION

Comatose survivors after cardiac arrest and cardiopulmonary
resuscitation (CPR)

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Consideration of circumstances surrounding cardiopulmonary
    resuscitation (CPR), including anoxia time, duration of CPR, cause
    of cardiac arrest, and type of cardiac arrhythmia

2.  Measurement of body temperature

3.  Consideration of clinical findings of neurologic examination

4.  Electrophysiologic tests, including electroencephalogram (EEG) and
    evoked/event-related potential (EP) studies

5.  Biochemical markers, including neuron-specific enolase (NSE) and
    serum S100

6.  Monitoring of intracranial pressure and brain oxygenation

7.  Neuroimaging studies, including computed tomography (CT) and
    magnetic resonance imaging (MRI)

#### MAJOR OUTCOMES CONSIDERED

Rate of death or unconsciousness after 1 month or unconsciousness or
severe disability after 6 months

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Literature Search**

The Mayo Clinic Library and the Biomedical Library Information Service
of the University of Minnesota searched MEDLINE from January 1966 to
January 2006. Review articles and monographs were additionally
consulted. Search entries included the following text words and Medical
Subject Heading (MeSH) terms associated with cardiorespiratory
resuscitation: \"coma,\" \"anoxic encephalopathy,\" \"prognosis,\"
\"electrophysiological studies,\" and \"biochemical markers.\"

**Selection of Studies**

The guideline developers excluded studies in which coma was not
adequately described, single case reports, papers dealing with selected
subgroups of patients, and papers written in a language other than
English, German, French, or Italian or when an English translation was
not available. Selected articles fulfilled the following inclusion
criteria: documented cardiac arrest, age [\>]{.underline}17 years, and
accepted the following definitions of coma: Glasgow Coma Scale score sum
score [\<]{.underline}8, \"persistent unresponsiveness,\" and \"not
regaining consciousness.\" Poor outcome was defined as 1) death or
persisting unconsciousness after 1 month or 2) death, persisting
unconsciousness, or severe disability requiring full nursing care after
6 months. These outcome measures were chosen because the chance of
survival without severe motor or cognitive disability is virtually nil
in patients who are vegetative [\>]{.underline}1 month or more after
cardiopulmonary resuscitation (CPR) or in patients who are severely
disabled after [\>]{.underline}6 months.

The authors obtained 391 potentially eligible literature citations that
were reviewed in full by members of the practice parameter group. They
additionally reviewed authoritative position papers on permanent
vegetative state, withdrawal of care in the intensive care unit, and
communication with the family.

#### NUMBER OF SOURCE DOCUMENTS

Four class I studies, three class II studies, and five class III studies
were reviewed on circumstances surrounding cardiopulmonary resuscitation
(CPR) and clinical features. One class I study, one class II study, and
nine class III studies were reviewed on electrophysiologic studies. One
class I study, 11 class III studies, and three class IV studies were
reviewed on biochemical markers. Ten class IV studies were reviewed on
monitoring brain function and neuroimaging.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Classification of Evidence for Prognostic Article**

**Class I**: Evidence provided by a prospective study of a broad
spectrum of persons who may be at risk for developing the outcome (e.g.,
target disease, work status). The study measures the predictive ability
using an independent gold standard for case definition. The predictor is
measured in an evaluation that is masked to clinical presentation, and
the outcome is measured in an evaluation that is masked to the presence
of the predictor. All patients have the predictor and outcome variables
measured.

**Class II**: Evidence provided by a prospective study of a narrow
spectrum of persons at risk for having the condition, or by a
retrospective study of a broad spectrum of persons with the condition
compared to a broad spectrum of controls. The study measures the
prognostic accuracy of the risk factor using an acceptable independent
gold standard for case definition. The risk factor is measured in an
evaluation that is masked to the outcome.

**Class III**: Evidence provided by a retrospective study where either
the persons with the condition or the controls are of a narrow spectrum.
The study measures the predictive ability using an acceptable
independent gold standard for case definition. The outcome, if not
objective, is determined by someone other than the person who measured
the predictor.

**Class IV**: Any design where the predictor is not applied in an
independent evaluation OR evidence provided by expert opinion or case
series without controls.

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis of Randomized Controlled Trials\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

When data could be abstracted from the articles, the guideline
developers calculated sensitivity, false-positive rate (FPR) (1 --
specificity), and corresponding 95% confidence interval (CI). They chose
to report our calculation of the FPR because clinicians need to be
informed about the ability of the clinical examination and laboratory
tests to predict poor outcome with a high level of certainty (low FPR).
They calculated 95% CIs for sensitivity and FPR using Wilson\'s method.
For meta-analyses, they assessed heterogeneity with the chi-squared
test. In the absence of heterogeneity, they used the fixed-effects
method to pool the data.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Other

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

An international group was formed to review the prognostic value of the
clinical examination and of ancillary investigations
(electrophysiologic, biochemical, and radiologic) for poor outcome in
comatose survivors after cardiopulmonary resuscitation (CPR). The
guideline developers specifically assessed the value of the following
seven variables to predict poor outcome: Circumstances surrounding CPR,
elevated body temperature, neurologic examination, electrophysiologic
studies, biochemical markers, monitoring of brain function, and
neuroimaging studies.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Classification of Recommendations**

**A** = Established as effective, ineffective, or harmful for the given
condition in the specified population (Level A rating requires at least
two consistent Class I studies.)

**B** = Probably effective, ineffective, or harmful for the given
condition in the specified population (Level B rating requires at least
one Class I study or at least two consistent Class II studies).

**C** = Possibly effective, ineffective, or harmful for the given
condition in the specified population (Level C rating requires at least
one Class II study or two consistent Class III studies.)

**U** = Data inadequate or conflicting; given current knowledge,
predictor is unproven.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

This guideline was approved by the Quality Standards Subcommittee on
January 28, 2006; by the Practice Committee on April 27, 2006; and by
the American Academy of Neurology (AAN) Board of Directors on May 4,
2006.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the strength of the recommendations (A, B, C, U) and
classification of the evidence (Class I through Class IV) are provided
at the end of the \"Major Recommendations\" field.

**Results and Recommendations**

*Are the circumstances surrounding cardiopulmonary resuscitation (CPR)
predictive of outcome?*

Prognosis cannot be based on the circumstances of cardiopulmonary
resuscitation (**recommendation level B**).

*Is hyperthermia predictive of outcome?*

Prognosis cannot be based on elevated body temperature alone
(**recommendation level C**).

*Which features of the neurologic examination of the comatose patient
are predictive of outcome?*

The prognosis is invariably poor in comatose patients with absent
pupillary or corneal reflexes, or absent or extensor motor responses 3
days after cardiac arrest (**recommendation level A**). Patients with
myoclonus status epilepticus within the first day after a primary
circulatory arrest have a poor prognosis (**recommendation level B**).

*Which electrophysiologic studies are helpful in determining outcome?*

Burst suppression or generalized epileptiform discharges on
electroencephalogram (EEG) predicted poor outcomes but with insufficient
prognostic accuracy (**recommendation level C**).

The assessment of poor prognosis can be guided by the bilateral absence
of cortical somatosensory evoked potentials (SSEPs) (N20 response)
within 1 to 3 days (**recommendation level B**).

*Do biochemical markers accurately predict outcome?*

Serum neuron-specific enolase (NSE) levels \>33 micrograms/L at days 1
to 3 post-CPR accurately predict poor outcome (**recommendation level
B**). There are inadequate data to support or refute the prognostic
value of other serum and cerebrospinal fluid (CSF) biochemical markers
in comatose patients after CPR (**recommendation level U**).

*Does monitoring of intracranial pressure and brain oxygenation predict
outcome?*

There are inadequate data to support or refute the prognostic value of
intracranial pressure (ICP) monitoring (**recommendation level U**).

*Are neuroimaging studies indicative of outcome?*

There are inadequate data to support or refute whether neuroimaging is
indicative of poor outcome (**recommendation level U**).

**[Definitions]{.underline}**:

**Classification of Evidence for Prognostic Article**

**Class I**: Evidence provided by a prospective study of a broad
spectrum of persons who may be at risk for developing the outcome (e.g.
target disease, work status). The study measures the predictive ability
using an independent gold standard for case definition. The predictor is
measured in an evaluation that is masked to clinical presentation, and
the outcome is measured in an evaluation that is masked to the presence
of the predictor. All patients have the predictor and outcome variables
measured.

**Class II**: Evidence provided by a prospective study of a narrow
spectrum of persons at risk for having the condition, or by a
retrospective study of a broad spectrum of persons with the condition
compared to a broad spectrum of controls. The study measures the
prognostic accuracy of the risk factor using an acceptable independent
gold standard for case definition. The risk factor is measured in an
evaluation that is masked to the outcome.

**Class III**: Evidence provided by a retrospective study where either
the persons with the condition or the controls are of a narrow spectrum.
The study measures the predictive ability using an acceptable
independent gold standard for case definition. The outcome, if not
objective, is determined by someone other than the person who measured
the predictor.

**Class IV**: Any design where the predictor is not applied in an
independent evaluation OR evidence provided by expert opinion or case
series without controls.

**Classification of Recommendations**

**A** = Established as effective, ineffective, or harmful for the given
condition in the specified population. (Level A rating requires at least
two consistent Class I studies.)

**B** = Probably effective, ineffective, or harmful for the given
condition in the specified population (Level B rating requires at least
one Class I study or at least two consistent Class II studies.)

**C** = Possibly effective, ineffective, or harmful for the given
condition in the specified population (Level C rating requires at least
one Class II study or two consistent Class III studies.)

**U** = Data inadequate or conflicting; given current knowledge,
predictor is unproven.

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document, titled
\"Decision algorithm for use in prognostication of comatose survivors
after cardiopulmonary resuscitation.\"

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Accurate prediction of outcomes in comatose survivors after cardiac
arrest and cardiopulmonary resuscitation (CPR)

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This statement is provided as an educational service of the American
Academy of Neurology (AAN). It is based on an assessment of current
scientific and clinical information. It is not intended to include all
possible proper methods of care for a particular neurologic problem or
all legitimate criteria for choosing to use a specific procedure, nor is
it intended to exclude any reasonable alternative methodologies. The AAN
recognizes that specific patient care decisions are the prerogative of
the patient and physician caring for the patient, based on all the
circumstances involved.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Patient Resources\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S, Quality Standards
Subcommittee of the American Academy of Neurology. Practice parameter:
prediction of outcome in comatose survivors after cardiopulmonary
resuscitation (an evidence-based review): report of the Quality
Standards Subcommittee of the American Academy of Neurology.
Neurology 2006 Jul 25;67(2):203-10. \[71 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16864809)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Jul

#### GUIDELINE DEVELOPER(S)

American Academy of Neurology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Neurology (AAN)

#### GUIDELINE COMMITTEE

Quality Standards Subcommittee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: E.F.M. Wijdicks, MD; A. Hijdra, MD; G.B. Young, MD;
C.L. Bassetti, MD; S. Wiebe, MD

*Quality Standards Committee Members*: Gary Gronseth, MD (*Co-Chair*);
Jacqueline French, MD (*Co-Chair*); Charles E. Argoff, MD; Stephen
Ashwal, MD (ex-officio); Christopher Bever, Jr., MD; John D. England,
MD; Gary Franklin, MD, MPH (ex-officio); Gary H. Friday, MD; Larry B.
Goldstein, MD; Deborah Hirtz, MD (ex-officio); Robert G. Holloway, MD,
MPH; Donald J. Iverson, MD; Leslie Morrison, MD; Clifford J. Schostal,
MD; David J. Thurman, MD; Samuel Wiebe, MD (facilitator); William J.
Weiner, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The authors report no conflicts of interest.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: A list of American Academy of Neurology (AAN)
guidelines, along with a link to a Portable Document Format (PDF) file
for this guideline, is available at the [AAN Web
site](http://aan.com/go/practice/guidelines).

Print copies: Available from the AAN Member Services Center, (800)
879-1960, or from AAN, 1080 Montreal Avenue, St. Paul, MN 55116.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   AAN guideline development process \[online\]. St. Paul (MN):
    American Academy of Neurology. Available from the [American Academy
    of Neurology Web
    site](http://aan.com/go/practice/guidelines/development).

-   Prediction of outcome in comatose survivors after cardiopulmonary
    resuscitation. AAN summary of evidence-based guideline for
    clinicians. St. Paul (MN): American Academy of Neurology. 2 p.
    Available in Portable Document Format (PDF) from the [American
    Academy Neurology Web
    site](http://aan.com/professionals/practice/guidelines/coma_clinician.pdf).

#### PATIENT RESOURCES

The following is available:

-   Prediction of recovery from coma after CPR. AAN summary of
    evidence-based guideline for patients and their families. St. Paul
    (MN): American Academy of Neurology (AAN). 2 p.

Electronic copies: Available in Portable Document Format (PDF) from the
[AAN Web
site](http://aan.com/professionals/practice/guidelines/coma_patient.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on October 2, 2006. The
information was verified by the guideline developer on November 1, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the American Academy of Neurology

### DISCLAIMER

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Date Modified: 11/10/2008