Post-Cardiac-Arrest Neuroprognostication — free guideline decision tool

Multimodal neuroprognostication for comatose survivors of cardiac arrest, requiring concordant unfavorable indicators after a defined delay.

At ≥ 72 h in a comatose patient (M ≤ 3), ≥ 2 concordant unfavorable indicators (absent pupillary/corneal reflexes, absent bilateral N20, malignant EEG, NSE > 60, status myoclonus, diffuse anoxic injury on CT/MRI) suggest poor prognosis; no single indicator decides.

Use ≥ 72 h after ROSC, with confounders excluded, to combine clinical, electrophysiologic, biomarker, and imaging indicators.

Premature assessment (< 72 h or with sedation/hypothermia confounders) is unreliable and risks inappropriate withdrawal of care (original synthesis · not guideline verbatim). A single positive indicator is insufficient; at least two concordant findings plus multidisciplinary consensus are required. Absent motor response or the GCS-M item alone has a high false-positive rate and must not determine prognosis.

For licensed clinicians and clinical researchers. Interpret results with history, investigations and local protocols; not a diagnosis or prescription, and not a substitute for multidisciplinary decision-making or local guidelines.

Inputs: Assessment timing ≥ 72 h after ROSC, with sedation/paralysis/hypothermia and other confounders excluded, Bilateral pupillary + corneal reflexes absent (≥ 72 h) No, Bilateral N20 (SSEP) absent No, Highly malignant EEG (> 24 h, suppression/burst-suppression) No, NSE > 60 µg/L (48 and/or 72 h) No, Status myoclonus (≤ 72 h, early generalized) No, CT/MRI diffuse extensive anoxic injury No → Result: Neuroprognosis No poor-prognosis predictors (not equivalent to good prognosis)（Positive indicators: 0 → No poor-prognosis predictors (not equivalent to good prognosis), Decision rule: For a comatose patient (M ≤ 3) at ≥ 72 h, ≥ 2 concordant unfavorable indicators are required to suggest poor prognosis; no single indicator decides alone. The result must reach multidisciplinary consensus and be combined with clinical context, Reliable indicators: Bilateral pupillary + corneal reflexes absent ≥ 72 h, bilateral N20 absent, highly malignant EEG > 24 h, NSE > 60 (a rising trend is more supportive), status myoclonus ≤ 72 h, CT/MRI diffuse anoxic injury） Inputs: Assessment timing < 72 h or confounders still present, Bilateral pupillary + corneal reflexes absent (≥ 72 h) Yes, Bilateral N20 (SSEP) absent Yes, Highly malignant EEG (> 24 h, suppression/burst-suppression) Yes, NSE > 60 µg/L (48 and/or 72 h) Yes, Status myoclonus (≤ 72 h, early generalized) Yes, CT/MRI diffuse extensive anoxic injury Yes → Result: Neuroprognosis Defer (timing not reached/confounders present)（Principle: Reliable prognostication should be performed ≥ 72 h after ROSC, with sedation/paralysis/hypothermia/metabolic confounders excluded; premature assessment is unreliable — avoid premature withdrawal of life-sustaining therapy (WLST), Current positive indicators: 6 (for reference only; no conclusion before the assessment window), Basis: ERC-ESICM 2021/2025 neuroprognostication guidelines; AHA 2020）