Serial Neurologic Examinations After Near Drowning and Outcome

Bratton, Susan L.; Jardine, David S.; Morray, Jeffrey P.

doi:10.1001/archpedi.1994.02170020053008

Cited by 55 publications

(30 citation statements)

References 15 publications

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“…These results stress the importance of the neurological examination in assessing postcardiac arrest patients and suggest that emphasis should be placed on teaching the skills required to conduct and interpret quality neurological examinations. 17,18 …”

Section: Discussionmentioning

confidence: 99%

Neuroprognostication After Pediatric Cardiac Arrest

Kirschen

Topjian

Hammond

et al. 2014

Pediatric Neurology

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BACKGROUND Management decisions and parental counseling after pediatric cardiac arrest depend on the ability of physicians to make accurate and timely predictions regarding neurological recovery. We evaluated neurologists and intensivists performing neuroprognostication after cardiac arrest to determine prediction agreement, accuracy, and confidence. METHODS Pediatric neurologists (n = 10) and intensivists (n = 9) reviewed 18 cases of children successfully resuscitated from a cardiac arrest and managed in the pediatric intensive care unit. Cases were sequentially presented (after arrest day 1, days 2–4, and days 5–7), with updated examinations, neurophysiologic data, and neuroimaging data. At each time period, physicians predicted outcome by Pediatric Cerebral Performance Category and specified prediction confidence. RESULTS Predicted discharge Pediatric Cerebral Performance Category versus actual hospital discharge Pediatric Cerebral Performance Category outcomes were compared. Exact (Predicted Pediatric Cerebral Performance Category – Actual Pediatric Cerebral Performance Category = 0) and close (Predicted Pediatric Cerebral Performance Category – Actual Pediatric Cerebral Performance Category = ±1) outcome prediction accuracies for all physicians improved over successive periods (P < 0.05). Prediction accuracy did not differ significantly between physician groups at any period or overall. Agreement improved over time among neurologists (day 1 Kappa [κ], 0.28; days 2–4 κ, 0.43; days 5–7 κ, 0.68) and among intensivists (day 1 κ, 0.30; days 2–4 κ, 0.44; days 5–7 κ, 0.57). Prediction confidence increased over time (P < 0.001) and did not differ between physician groups. CONCLUSIONS Inter-rater agreement among neurologists and among intensivists improved over time and reached moderate levels. For all physicians, prediction accuracy and confidence improved over time. Further prospective research is needed to better characterize how physicians objectively and subjectively estimate neurological recovery after acute brain injury.

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Section: Discussionmentioning

confidence: 99%

Neuroprognostication After Pediatric Cardiac Arrest

Kirschen

Topjian

Hammond

et al. 2014

Pediatric Neurology

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“…Neurologic examinations should be serially repeated including level of consciousness, pupillary reactivity, brain stem reflexes, and motor function. Drowning victims have recovered motor function as late as 48 h after resuscitation [127,128]. CA data supports these findings [70,71,124,129,130].…”

Section: Neurologic Examinationmentioning

confidence: 71%

“…• 7 LOE P3 studies indicating benefit [120,122,123,128,132,153,320], 1 indicating neutral effects [121], and 1 indicating harm [85] in drowning.…”

Section: Neuromonitoringmentioning

confidence: 99%

Brain Resuscitation in the Drowning Victim

Warner

Knape

2006

Handbook on Drowning

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. This manuscript is dedicated to the memory of Peter Safar, M.D. Peter Safar combined genius, incredible purpose, elegance, and humanism to move the collective fields of acute medicine to a new level. His work in resuscitation medicine, critical care, anesthesiology, emergency medicine, and disaster medicine saved countless lives. As a mentor he taught us a great deal. Peter left us with an important message-in both clinical care and research: namely, to always ask, "what is your intervention or research doing for the patient?" Whether physician or scientist, it is a critical message never to forget.Portions of this manuscript are being reproduced in the Handbook of Drowning. Bierens JJ (ed.). Springer, 2nd Edition. NIH Public Access AbstractDrowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32-34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating nonconvulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific postresuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/ reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.

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“…22,[51][52][53][54][55] Factors identifiable at hospital admission include level of consciousness, especially if unconsciousness is prolonged; elevated serum glucose; hypothermia; and signs of brain stem dysfunction, such as absent pupillary reflex, absent spontaneous respiration, and Pediatric Risk of Mortality (PRISM) scores. 24,26,73,74 Of note, age has no independent association with outcome. 52,75,76 …”

Section: Outcomementioning

confidence: 95%