Resuscitation Best Practices: A Guide to Neurological Prognostication

When a Code Blue is called, every responder knows the importance of a well-executed, timely response. In fact, the patient’s life depends on it. Since every second counts, any delay in care or deviation from best practices can affect the ultimate outcome. With those kinds of stakes, it’s no wonder that Code Blue training and preparation often centers heavily on the response itself.

But with so much emphasis on responding quickly and achieving return of spontaneous circulation (ROSC), equally critical factors like post-cardiac arrest care don’t always get the attention they deserve.

One example is neurological prognostication. Although essential to post-cardiac arrest care, it’s not always top of mind for responders. And organizations like The Joint Commission (TJC) are taking notice. It’s likely one of the reasons that TJC’s revised resuscitation standards now require hospitals to establish and adhere to research-backed neuroprognostication policies and protocols.  

Keep reading to learn the basics of neurological prognostication that all responders should know: why it matters, what tools clinicians have available to them, and tips to improve prognostic accuracy.

Neurological prognostication: Why does it matter?

Life-or-death decision making doesn’t end once the patient achieves ROSC. For patients who survive the arrest but face significant neurological injury afterward, clinicians need to make an informed decision about whether to continue or withdraw life-sustaining measures. Properly assessing a patient’s neurological status is a crucial piece of that process.

But that doesn’t mean it’s easy. In fact, there are risks on either side of the equation. An overly negative prognosis can lead providers to prematurely remove life support measures to a patient who might still have a chance. On the other hand, acting too conservatively isn’t always the best alternative. Not only is it costly to continue care for a patient who isn’t likely to recover, it can also add unnecessary emotional turmoil for the family.

Tools to use

Tools available

Deciding whether to remove life support is a daunting task that no clinician takes lightly. So what tools do providers have at their disposal to aid in the decision? Ultimately, the most accurate prognostication is multifaceted, drawing upon data from several sources. The main neurological assessments include¹:

• Level of consciousness and ability to follow commands immediately after ROSC
• Electroencephalography (EEG)
• CT scan
• MRI

Weighing the pros and cons

Each tool has its own strengths and weaknesses that clinicians should keep in mind. The top considerations include:

Timing

Some evaluations can be performed immediately; others take longer. CT scan and MRI, for example, require the patient to be stable to perform the testing. The results are then sent to neurology for interpretation with input from radiology. As a result, many patients will continue to receive life-saving measures while awaiting true neurological prognostication.

Objectivity

Ability to follow commands post-ROSC is traditionally a strong predictor of neurological outcome, but results may be interpreted differently depending on the provider. On the other hand, EEG, CT scan, and MRI take longer to perform and interpret but provide more objective data.

Confounding variables

Common post-ROSC interventions like targeted temperature management (TTM) and CT scan often require sedation, analgesia, and neuromuscular blockade (NMB). But these medications can also interfere with aspects of the neurological assessment, particularly physical findings such as pupillary changes. If not properly accounted for, this can lead to inappropriately low Cerebral Performance Category (CPC) scoring and inaccurate prognosis.² A CPC of 1-2 is considered a good outcome, whereas a CPC of 3-5 is associated with poor neurological outcome and brain death.

Tips to improve accuracy

What can clinicians do to balance these considerations and arrive at the most accurate prognosis?

1. Focus on a multimodal approach

As demonstrated above, no single prognostication tool is definitive. Consider all the data available to the team before reaching a prognosis.

2. Account for confounding variables

Despite some inherent subjectivity, level of consciousness and ability to follow commands are still some of the best prognostic indicators post-arrest. To ensure the highest level of accuracy, consider any medications in the patient’s system that might affect these evaluations.

• Per American Heart Association recommendations, limit use of sedatives, analgesia, and NMB as reasonable to decrease the impact to neurological assessment.³
• When it’s not possible to limit these drugs, use caution when interpreting neurological findings. The medications may contribute to delayed wake-up, pupillary changes, and more.

3. Allow enough time

While prognostication shouldn’t drag on unnecessarily, don’t rush to reach a decision either. Typically, it’s not advisable to begin prognostic evaluation sooner than 72 hours post-arrest.⁴ Why? Given that multiple data points are needed, it is important to allow enough time to obtain the tests, interpret the results, and consider the full neurologic picture. Similarly, clinicians need to leave enough time to account for and exclude any confounding variables that may interfere with neurological assessment.

4. Regularly review neurological prognostication policies/procedures

Doing so will undoubtedly help TJC-compliant hospitals adhere to the new standards. But for any hospital, the exercise will also encourage consistency across clinicians and ensure protocols are up-to-date based on current research. Establishing a more standardized TTM shivering protocol at your hospital for sedation, analgesia, and NMB can also help clinicians gain a better understanding of its effect on neurological prognostication.