With respect to neurological recovery after out of hospital cardiac arrest, discuss the factors which may confound prognostication and how they can be minimised.
Minimising the confounders
Overall poorly answered with limited detail and little attention paid to the factors which confound prognostication.
This question has apppeared many times before in varying forms. This incarnation most closely resembles Question 4 from the second paper of 2014. This time, of the confounding factors, the college also asked "and how they can be minimised". The table below was plagiarised from the chapter on prognostication after cardiac arrest, with little modification
|Predictive sign or investigation||Confounding factors||Strategies to minimise confounding factors|
|Absent pupillary reflex||
|Absent corneal reflex|
|Extensor motor response, or worse||
|Myoclonic status epilepticus||
|Somatosensory evoked potentials:
absence of the N20 component
|Burst suppression on EEG||
|Absence of EEG reactivity||
Engdahl, Johan, et al. "Can we define patients with no and those with some chance of survival when found in asystole out of hospital?." The American journal of cardiology 86.6 (2000): 610-614.
Bunch, T. Jared, et al. "Outcomes and in-hospital treatment of out-of-hospital cardiac arrest patients resuscitated from ventricular fibrillation by early defibrillation." Mayo Clinic Proceedings. Vol. 79. No. 5. Elsevier, 2004.
Levine, Robert L., Marvin A. Wayne, and Charles C. Miller. "End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest." New England Journal of Medicine 337.5 (1997): 301-306.
Rea, Thomas D., et al. "Temporal Trends in Sudden Cardiac Arrest A 25-Year Emergency Medical Services Perspective." Circulation 107.22 (2003): 2780-2785.
Carew, Heather T., Weiya Zhang, and Thomas D. Rea. "Chronic health conditions and survival after out-of-hospital ventricular fibrillation cardiac arrest." Heart 93.6 (2007): 728-731.
Goldberger, Zachary D., et al. "Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study." The Lancet (2012).
Wijdicks, E. F. M., et al. "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 67.2 (2006): 203-210.
Rogove, Herbert J., et al. "Old age does not negate good cerebral outcome after cardiopulmonary resuscitation: analyses from the brain resuscitation clinical trials."Critical care medicine 23.1 (1995): 18-25.
LEVY, DE, et al. "Predicting Outcome from Hypoxic-Ischemic Coma." Survey of Anesthesiology 30.2 (1986): 93.
Sandroni, Claudio, et al. "Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine." Resuscitation 85.12 (2014): 1779-1789.
Greer, David M., et al. "Clinical examination for prognostication in comatose cardiac arrest patients."Resuscitation 84.11 (2013): 1546-1551.
Lee, Ha Lim, and Ju Kang Lee. "Lance-adams syndrome." Annals of rehabilitation medicine 35.6 (2011): 939-943.
Bouwes, Aline, et al. "Acute posthypoxic myoclonus after cardiopulmonary resuscitation." BMC neurology 12.1 (2012): 63.
Stammet, Pascal, et al. "Neuron-specific enolase as a predictor of death or poor neurological outcome after out-of-hospital cardiac arrest and targeted temperature management at 33 C and 36 C." Journal of the American College of Cardiology 65.19 (2015): 2104-2114.
Golan, Eyal, et al. "Predicting Neurologic Outcome After Targeted Temperature Management for Cardiac Arrest: Systematic Review and Meta-Analysis*." Critical care medicine 42.8 (2014): 1919-1930.
Howes, Daniel, et al. "Canadian Guidelines for the use of targeted temperature management (therapeutic hypothermia) after cardiac arrest: A joint statement from The Canadian Critical Care Society (CCCS), Canadian Neurocritical Care Society (CNCCS), and the Canadian Critical Care Trials Group (CCCTG)." Resuscitation 98 (2016): 48-63.