Prognostication in comatose survivors of cardiac arrest: An advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine

Claudio Sandroni*, Alain Cariou, Fabio Cavallaro, Tobias Cronberg, Hans Friberg, Cornelia Hoedemaekers, Janneke Horn, Jerry P. Nolan, Andrea O. Rossetti, Jasmeet Soar

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

199 Citations (Scopus)


Objectives: To review and update the evidence on predictors of poor outcome (death, persistent vegetative state or severe neurological disability) in adult comatose survivors of cardiac arrest, either treated or not treated with controlled temperature, to identify knowledge gaps and to suggest a reliable prognostication strategy.

Methods: GRADE-based systematic review followed by expert consensus achieved using Web-based Delphi methodology, conference calls and face-to-face meetings. Predictors based on clinical examination, electrophysiology, biomarkers and imaging were included.

Results and conclusions: Evidence from a total of 73 studies was reviewed. The quality of evidence was low or very low for almost all studies. In patients who are comatose with absent or extensor motor response at ≥72 h from arrest, either treated or not treated with controlled temperature, bilateral absence of either pupillary and corneal reflexes or N20 wave of short-latency somatosensory evoked potentials were identified as the most robust predictors. Early status myoclonus, elevated values of neuron-specific enolase at 48–72 h from arrest, unreactive malignant EEG patterns after rewarming, and presence of diffuse signs of postanoxic injury on either computed tomography or magnetic resonance imaging were identified as useful but less robust predictors. Prolonged observation and repeated assessments should be considered when results of initial assessment are inconclusive. Although no specific combination of predictors is sufficiently supported by available evidence, a multimodal prognostication approach is recommended in all patients.

Original languageEnglish
Pages (from-to)1816-1831
Number of pages16
JournalIntensive Care Medicine
Issue number12
Publication statusPublished - 21 Nov 2014

Bibliographical note

Funding Information:
• Hans Friberg received lecture fees from Natus, Inc. (manufacturer of NervusMonitor, cont. EEG/aEEG) and from Bard Medical. He received grants from the EU Interreg. Programme IV A and academic research grants from multiple non-profit organisations for the Target Temperature Management trial (all data controlled by the investigators). He is the chair of the working party ‘‘Care after cardiac arrest’’, Swedish Resuscitation Council.

Funding Information:
• Janneke Horn received a grant from the Dutch Heart Foundation (2007B039) for the PROPAC II study and from the Dutch Brain Foundation (14F06.48) for research on SSEP during hypothermia treatment after cardiac arrest (data controlled by the investigator and no restrictions on publication). She is the principal investigator of the PROPACII study and co-author of a systematic review on diagnostic tools for prediction of poor outcome after cardiopulmonary resuscitation.

Publisher Copyright:
© 2014, The Author(s).

Copyright 2014 Elsevier B.V., All rights reserved.


  • Clinical examination
  • Coma
  • CT scan
  • Heart arrest
  • Magnetic resonance
  • Neuron specific enolase
  • Prognosis
  • Somatosensory evoked potentials

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