Clinical Approaches to Assess Neurological Outcomes of Cardiopulmonary Arrest in Unconscious Adults

Background Current guidelines to predicting 'poor' neurological outcome in post-arrest unconscious adults have not previously been analysed in detail and, authoritative guidance to prediction of 'good' neuroprognosis does not exist. Methods A narrative appraisal of guideline statements and presented clinical indices of 'poor' neuroprognosis and, a systematic review of reported bedside indicators of 'good' outcome. Results The overall quality of neuroprognostication studies is low. Current neuroprognostication guidelines focus exclusively on predicting 'poor' outcome of post-CA unconsciousness by static clinical and/or paraclinical tests 3-5 days after ROSC and yield indirect evidence only. The approach is weakened also because acknowledged 'poor' outcome signs can be indistinguishable from features of natural brain revival towards intact neurological survival. Guidelines do not address 'good' outcome indicators. Twenty-one studies on 'good' outcome parameters were identified. Eleven were of low or very low quality of evidence and ten studies poorer. Inclusion of individuals about-to or already-awake presumably biased 12 studies. However, the order, recovery rate and linkage of clinical features seem essential for monitoring and predicting the brain resuscitation course after cardiopulmonary arrest. Unconscious patients likely to make 'good' recoveries can be discerned from those with 'poor' neuro-perspectives by cranial nerve reflex findings during BLS and within 60 min from ROSC or by the results of cranial nerve reflex-, motor responses to 'pain'- and EEG investigations within the first few hours from ROSC. Patient's neurological performances or quality of life scores at best after awakening seem rational prognostication endpoints. Conclusion Serial bedside investigations deployed within minutes to a few hours during unconsciousness and longitudinal surveillance of patient's neurological faculties and quality of life scores after awakening are suggested to improve neuroprognostication in adults resuscitated from cardiopulmonary arrest.