November 16, 2010
Q: Is any time delay recommended to see what the neuro assessment is prior to sedating and cooling?
A: The way we do this at our institution, if there is a question regarding neurological status of a patient right after the arrest and sedation was given, sometimes, we will wait an hour, let the medications wear off and then decide if they are waking up. And by waking up I mean following commands appropriately. The patient has to be able to give a thumbs up or squeeze your hands appropriately for us to decide not to cool. Just moving extremities or "reaching of the ET tube" is not, for our determination, following commands appropriately. In our protocol we go with a Glasgow Motor Score of <6, which is not following commands, since a GMS of 6 is "following commands". I would recommend using GMS over the full GCS.
We always error on the side of cooling, since there are very little risks and very big benefits. We reason that we only have one chance to save the brain and if we decide not to cool because they some what look like they might be following commands or opening their eyes, there is no going back and we have lost our chance.
As always, these things are a case by case basis. If they arrested in the field and they are already paralyzed and sedated, we may just cool regardless.
- Marion Leary BSN, RN
August 10, 2010
Q: What does the evidence say about neurological assessment after a cardiac arrest patient is brought back to a normothermic level? Are there studdies available on how long we need to wait and be patient to see if the patient will make further progress?
A: In terms of neurological prognostication after cardiac arrest, currently the standard guidelines are to not neuro prognosticate until at least 72 hours post ROSC, by that time the patient should be re-warmed. Although the guidelines say 72 hours we have seen in our patients a range anywhere from 2 day post ROSC up to 14 days or more, with the average being 3-5 days. There was a Consensus statement put out by the International committee on Resuscitation, for which the AHA is a part of, which explains why older neurologic prognostication tests are not reliable and it also goes into more detail about prognostication in this population. There are new International/AHA guidelines coming out at the end of this year, so things may change even more, we will just have to wait and see.
- Marion Leary BSN, RN