Neurological prognostication after cardiac arrest: evidence review and institutional protocol proposal

Cardiac arrest (CA) is associated with high mortality and neurological morbidity, mainly due to hypoxic-ischemic encephalopathy. Accurate neurological prognostication in CA survivors is essential to guide therapeutic decisions and provide appropriate care.

To review the current evidence on neurological prognostication after CA and to propose an institutional protocol adapted to the resources of Hospital de Clínicas de Porto Alegre (HCPA).

The current narrative review was conducted in two stages: a literature review and the development of an institutional protocol. Articles were selected according to their clinical relevance and their contribution to current evidence on neurological prognostication after CA. The PubMed, Scopus, Web of Science, Embase, and SciELO databases were searched. The protocol was developed considering the clinical tools available at HCPA, including neurological examination, electroencephalography (EEG), and neuroimaging.

Brain injury after CA occurs in three stages: intra-arrest ischemia, immediate reperfusion, and delayed postreperfusion injury. Prognostic modalities include neurological examination, EEG, somatosensory-evoked potentials (SSEPs), serum biomarkers, and neuroimaging. Reliable predictors of poor outcome include absent brainstem reflexes at 72 hours, persistent EEG suppression, bilateral absence of cortical N20 potentials, and diffuse abnormalities on magnetic resonance imaging. The proposed protocol organizes assessments from admission to the Intensive Care Unit through day 5 after the return of spontaneous circulation.

A standardized post-CA neurological prognostication protocol at HCPA may improve care quality, enhance communication with families, and support ethically-sound decision-making.