Youn Chun Song, Callaway Clifton W, Rittenberger Jon C
Department of Emergency Medicine, The Catholic University of Korea, Republic of Korea.
Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States.
Resuscitation. 2015 Sep;94:73-9. doi: 10.1016/j.resuscitation.2015.06.016. Epub 2015 Jul 8.
Prognosticating outcome following cardiac arrest requires a multimodal approach. We tested whether the combination of initial neurologic examination combined with continuous EEG was superior to either test alone for predicting survival after cardiac arrest.
Review of consecutive patients receiving continuous EEG monitoring between April 2010 and June 2013. Initial neurologic examination was evaluated using the Full Outline of UnResponsiveness (FOUR) score and organ system dysfunction determined using the SOFA score. We defined four categories of initial post-cardiac arrest illness severity (PCAC): (I) awake, (II) coma (not following commands but intact brainstem responses) + mild cardiopulmonary dysfunction (SOFA cardiac + respiratory score < 4), (III) coma + moderate-severe cardiopulmonary dysfunction (SOFA cardiac + respiratory score ≥ 4), and (IV) coma without brainstem reflexes. A second analysis focusing on neurologic injury divided subjects into three groups according to initial FOUR_B score; FOUR_B = 0-1, FOUR_B = 2 and FOUR_B = 4. A blinded rater dichotomized continuous EEG patterns during the first 48h into malignant patterns (non-convulsive status epilepticus, convulsive status epilepticus, myoclonic status epilepticus and generalized periodic epileptiform discharges). The primary outcome was survival to hospital discharge.
Of 331 subjects, mean age was 58 (SD 17) years and 206 (62.2%) subjects were male. Ventricular fibrillation or tachycardia (VF/VT) was the initial rhythm for 93 (28.1%) subjects. Among subjects with malignant cEEG, survival to hospital discharge rate was 0% for FOUR_B 0-1, 8.1% for FOUR_B 2 and 12.5% for FOUR_B 4, respectively. In one multivariate analysis, survival was independently associated with VF/VT, FOUR_B of 2, FOUR_B of 4, and non-malignant cEEG. In a separate model, survival was associated with VF/VT, PCAC < 4 and non-malignant cEEG. The AUCs of FOUR_B, cEEG and the combination of FOUR_B and cEEG are 0.740 (95% C.I. 0.684-0.797), 0.674 (95% C.I. 0.615-0.732) and 0.820 (95% C.I. 0.773-0.868) respectively. The AUCs of PCAC, cEEG and the combination of PCAC and cEEG are 0.779 (95% C.I. 0.721-0.838), 0.672 (95% C.I. 0.612-0.7321) and 0.846 (95% C.I. 0.798-0.894) respectively.
Combining the initial neurologic examination using either FOUR_B or PCAC, with cEEG was superior to any individual test for predicting survival after cardiac arrest. We caution against using these findings to speed prognostication until they are externally validated.
预测心脏骤停后的预后需要采用多模式方法。我们测试了初始神经系统检查与连续脑电图（EEG）相结合是否比单独使用任何一种检查在预测心脏骤停后的生存情况方面更具优势。
回顾2010年4月至2013年6月期间接受连续EEG监测的连续患者。使用无反应性全面大纲（FOUR）评分评估初始神经系统检查，并使用序贯器官衰竭评估（SOFA）评分确定器官系统功能障碍。我们将心脏骤停后初始疾病严重程度（PCAC）分为四类：（I）清醒，（II）昏迷（不遵循指令但脑干反应完整）+轻度心肺功能障碍（SOFA心脏+呼吸评分<4），（III）昏迷+中度至重度心肺功能障碍（SOFA心脏+呼吸评分≥4），以及（IV）无脑干反射的昏迷。另一项侧重于神经损伤的分析根据初始FOUR_B评分将受试者分为三组；FOUR_B = 0 - 1、FOUR_B = 2和FOUR_B = 4。一名盲法评分者将最初48小时内的连续EEG模式分为恶性模式（非惊厥性癫痫持续状态、惊厥性癫痫持续状态、肌阵挛性癫痫持续状态和全身性周期性癫痫样放电）。主要结局是存活至出院。
在331名受试者中，平均年龄为58岁（标准差17），206名（62.2%）受试者为男性。心室颤动或室性心动过速（VF/VT）是93名（28.1%）受试者的初始心律。在恶性cEEG受试者中，FOUR_B 0 - 1组的出院存活率为0%，FOUR_B 2组为8.1%，FOUR_B 4组为12.5%。在一项多变量分析中，生存与VF/VT、FOUR_B为2、FOUR_B为4以及非恶性cEEG独立相关。在另一个模型中，生存与VF/VT、PCAC<4和非恶性cEEG相关。FOUR_B、cEEG以及FOUR_B与cEEG组合的曲线下面积（AUC）分别为0.740（95%置信区间0.684 - 0.797）、0.674（95%置信区间0.615 - 0.732）和0.820（95%置信区间0.773 - 0.868）。PCAC、cEEG以及PCAC与cEEG组合的AUC分别为0.779（95%置信区间0.721 - 0.838）、0.672（95%置信区间0.612 - 0.7321）和0.846（95%置信区间0.798 - 0.894）。
将使用FOUR_B或PCAC进行的初始神经系统检查与cEEG相结合，在预测心脏骤停后的生存情况方面优于任何单独的检查。在这些发现得到外部验证之前，我们提醒不要使用这些结果来加速预后判断。
