T h e ne w e ngl a nd jou r na l o f m e dicine n engl j med 369;23 nejm.org december 5, 2013

These Guidelines are based on the International Liaison Committee on Resuscitation (ILCOR) 2015 Consensus on Science and Treatment Recommendations (CoSTR) for ALS. 4 The 2015 ILCOR review focused on 42 topics organised in the approximate sequence of ALS interventions: defibrillation, airway, oxygenation and ventilation, circulatory support, monitoring during CPR, and drugs during CPR. For these Guidelines the ILCOR recommendations were supplemented by focused literature reviews undertaken by the ERC ALS Writing Group for those topics not reviewed in the 2015 ILCOR CoSTR. Guidelines were drafted and agreed by the ALS Writing Group members before final approval by the ERC General Assembly and ERC Board. Summary of changes since 2010 GuidelinesThe 2015 ERC ALS Guidelines have a change in emphasis aimed at improved care and implementation of these guidelines in order to improve patient focused outcomes. 5 The 2015 ERC ALS Guidelines do not include any major changes in core ALS interventions since the previous ERC guidelines published in 2010. 1,2 The key changes since 2010 are:• Continuing emphasis on the use of rapid response systems for care of the deteriorating patient and prevention of in-hospital cardiac arrest. • Continued emphasis on minimally interrupted high-quality chest compressions throughout any ALS intervention: chest

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Objective:To identify reliable predictors of outcome in comatose patients after cardiac arrest using a single routine EEG and standardized interpretation according to the terminology proposed by the American Clinical Neurophysiology Society.Methods:In this cohort study, 4 EEG specialists, blinded to outcome, evaluated prospectively recorded EEGs in the Target Temperature Management trial (TTM trial) that randomized patients to 33°C vs 36°C. Routine EEG was performed in patients still comatose after rewarming. EEGs were classified into highly malignant (suppression, suppression with periodic discharges, burst-suppression), malignant (periodic or rhythmic patterns, pathological or nonreactive background), and benign EEG (absence of malignant features). Poor outcome was defined as best Cerebral Performance Category score 3–5 until 180 days.Results:Eight TTM sites randomized 202 patients. EEGs were recorded in 103 patients at a median 77 hours after cardiac arrest; 37% had a highly malignant EEG and all had a poor outcome (specificity 100%, sensitivity 50%). Any malignant EEG feature had a low specificity to predict poor prognosis (48%) but if 2 malignant EEG features were present specificity increased to 96% (p < 0.001). Specificity and sensitivity were not significantly affected by targeted temperature or sedation. A benign EEG was found in 1% of the patients with a poor outcome.Conclusions:Highly malignant EEG after rewarming reliably predicted poor outcome in half of patients without false predictions. An isolated finding of a single malignant feature did not predict poor outcome whereas a benign EEG was highly predictive of a good outcome.

High, serial NSE values are strong predictors of poor outcome after OHCA. Targeted temperature management at 33°C or 36°C does not significantly affect NSE levels. (Target Temperature Management After Cardiac Arrest [TTM]; NCT01020916).