Evaluation of hypoxic ischemic injury algorithm. S sedatives, A analgesics, B neuromuscular junction blockers, H hypothermia
MRI may become abnormal if repeated, but there are patients with repeatedly normal MRI who never awaken only to demonstrate generalized brain atrophy later.
17.3.5 Prognostication Summary
Anoxic-ischemic injury remains the primary cause of disability post-cardiac arrest . Targeted hypothermia is standard of care in many hospitals with modern ICUs, but the practice varies. Uncertainties about the timing of initial therapy, duration of therapy, best means to cool, and target temperature during therapeutic hypothermia exist. Prognostication in these comatose patients remains unreliable if there is (1) no myoclonus status, (2) present brainstem reflexes, (3) no suppression of EEG background or burst suppression pattern, (4) normal or near normal MRI, and (5) normal SSEPs. This means that in the majority of patients, outcome cannot be clearly established in the first weeks. Failure to improve motor response to localization implies longstanding cognitive deficits and even failure to awaken beyond a minimally conscious state. Neurologic assessment remains key and cannot be replaced by any ancillary test. Thus, neurologists and neurology specialty trained providers will continue to be consulted to perform thorough neurological examinations on patients post-cardiac arrest and provide their expertise in treating and prognostication to guide the primary care providers and families in determining goals of care.
Targeted hypothermia is the primary treatment strategy following cardiac arrest to preserve neurological function.
Shivering is expected with therapeutic hypothermia and should be treated with sedatives, opioids, or neuromuscular blockade agents.
Repeat neurologic examination without confounders often predicts poor outcome.
MRI and SSEP are helpful for determining degree of injury.
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