Clinical examination for outcome prediction in nontraumatic coma

Crit Care Med. 2012 Apr;40(4):1150-6. doi: 10.1097/CCM.0b013e318237bafb.

Abstract

Objectives: Determine the utility of the neurologic examination in comatose patients from nontraumatic causes in the modern era.

Design: Prospective observational study.

Setting: Single academic medical center.

Patients: Data from 500 patients in nontraumatic coma collected sequentially from 2000 to 2007 in the emergency department and neuroscience, medical, and cardiac intensive care units.

Interventions: None.

Measurements and main results: Clinical data were collected on days 0, 1, 3, and 7. Outcome was assessed at 6 months; good outcome was determined at two levels by modified Rankin Scale, ≤3 as independence and ≤4 as moderate but not severe disability. A classification and regression tree analysis was performed to determine prognostic variables, creating predictive algorithms of good vs. poor outcome for each day. Patients with coma attributable to subarachnoid hemorrhage (4/80; 5%) or global hypoxic-ischemic injury (20/202, 10%) were more likely to achieve good outcomes. The pupillary reflex was an important determinant, regardless of day or modified Rankin Scale cut point (mean odds ratio 12.51, range [6.01, 22.56] for modified Rankin Scale ≤3; mean odds ratio 19.26, range [5.38, 42.26] for modified Rankin Scale ≤4). A less robust effect was seen for oculocephalic reflexes (mean odds ratio 62.61, range [2.24, 177] for modified Rankin Scale ≤3; mean odds ratio 34.13, range [4.95, 89.93] for modified Rankin Scale ≤4). The motor response was selected as a predictor of outcome only on day 0 (odds ratio 2.35, 95% confidence interval 0.64-5.74 for modified Rankin Scale ≤3; odds ratio 2.1, 95% confidence interval 0.81-4.24 for modified Rankin Scale score ≤4). Age was not associated with outcome.

Conclusions: The clinical neurologic examination remains central to determining prognosis in nontraumatic coma. Additional clinical and diagnostic variables may also aid in outcome prediction for specific disease states.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Algorithms
  • Chi-Square Distribution
  • Coma / diagnosis*
  • Coma / etiology
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Humans
  • Hypoxia
  • Hypoxia-Ischemia, Brain / complications
  • Male
  • Middle Aged
  • Neurologic Examination* / methods
  • Neurologic Examination* / statistics & numerical data
  • Outcome Assessment, Health Care* / methods
  • Prospective Studies
  • Reflex, Pupillary
  • Statistics, Nonparametric
  • Subarachnoid Hemorrhage / complications
  • Treatment Outcome