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REPLY

Dean D. Bell, MD^*, Peter G. Brindley, MD, Osama Al Muslim, MD and David Zygun, MD

^* University of Manitoba, Winnipeg, Canada
University of Alberta, Edmonton, Canada
University of Western Ontario, London, Canada
University of Calgary, Calgary, Canada, E-mail: Dean1{at}mts.net

We appreciate the positive comment of Mitchell et al. regarding our recommendations for management of patients resuscitated from cardiac arrest. Unfortunately, many recommendations are based on low grade evidence, and we agree further debate and investigation are required. Mitchell et al. cite a 4% reported incidence of subarachnoid hemorrhage (SAH) causing out-of hospital arrest as justification for routine computed tomography (CT) head scans in post arrest patients who remain unconscious.¹ We agree that therapeutic hypothermia may pose problems in patients suffering from SAH. We note, however, that Kurkciyan et al. reported only 4/765 (0.5%) patients arrested following a SAH that was not suspected upon clinical grounds.¹ We do not believe this rate is high enough to justify routine CT scanning in all comatose patients following resuscitation from cardiac arrest. We continue to recommend head CT scans only when clinical findings support ordering the scan.²

We are aware of data that may change the recommendation. Torbey et al. have published data combining CT scan results with clinical assessment as a predictor of outcome following resuscitation from cardiac arrest.³ If CT scans can be shown to improve the ability to predict outcome in post arrest patients we could support routine CT scans. At this point we need further evidence to evaluate the utility of the Brain Arrest Neurological Outcome Scale approach or other CT or magnetic resonance imaging based prognostic scores. We anticipate the recommendations will evolve as research is reported, and welcome debate and interest in the topic.

References

1 Kurkciyan I, Meron G, Sterz F, et al. Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest. Resuscitation 2001; 51: 27–32.[Medline]

2 Bell DD, Brindley PG, Forrest D, Al Muslim O, Zygun D. Management following resuscitation from cardiac arrest: recommendations from the 2003 Rocky Mountain Critical Care Conference. Can J Anesth 2005; 52: 309–22.[Abstract/Free Full Text]

3 Torbey MT, Geocadin R, Bhardwaj A. Brain arrest neurological outcome scale (BrANOS): predicting mortality and severe disability following cardiac arrest. Resuscitation 2004; 63: 55–63.[Medline]

Related articles in CJA:

Head computed tomography scan following cardiac arrest

Joellene R. Mitchell, Paul Jefferson, and David R. Ball
CJA 2005 52: 892. [Full Text]  

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