SCOPE: Acute management, targeted temperature management (TTM), neuroprognostication, and rehabilitation pathway for anoxic brain injury following cardiac arrest or other causes of global cerebral hypoxia in adults. Covers post-cardiac arrest care bundle (TTM 32-36C for 24h, hemodynamic optimization, seizure management), multimodal neuroprognostication (clinical exam, EEG, SSEP, MRI, biomarkers, CT), confounder identification and elimination, myoclonus classification, and rehabilitation pathway for survivors. Excludes neonatal HIE, pediatric cardiac arrest, primary respiratory arrest without cardiac arrest, focal stroke, and traumatic brain injury.
DEFINITIONS:
- Anoxic Brain Injury (ABI): Diffuse brain injury from global cessation of cerebral blood flow (cardiac arrest) or oxygen delivery (severe hypoxia)
- Post-Cardiac Arrest Syndrome (PCAS): Multi-organ dysfunction following ROSC, including anoxic brain injury, myocardial dysfunction, systemic ischemia-reperfusion injury, and persistent precipitating pathology
- Targeted Temperature Management (TTM): Controlled cooling to 32-36C for at least 24h to reduce secondary neuronal injury
- Neuroprognostication: Multimodal assessment of neurological outcome performed no earlier than 72h after return to normothermia
- Lance-Adams Syndrome: Chronic post-hypoxic action myoclonus in cardiac arrest survivors who regain consciousness; distinct from early status myoclonus and compatible with good outcome
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
CRITICAL: NEUROPROGNOSTICATION TIMING
Do NOT prognosticate before 72 hours after return to normothermia (rewarming). Earlier assessment is unreliable due to residual effects of sedation, hypothermia, metabolic derangements, and neuromuscular blocking agents. No single test is sufficient for prognostication — a multimodal approach is mandatory (AAN 2023, ERC/ESICM 2021).
Prognostic biomarker; draw at 24h, 48h, and 72h post-ROSC. NSE >33 ug/L at 48-72h associated with poor outcome (FPR <5% per ERC/ESICM 2021). Must exclude hemolysis (falsely elevates NSE)
<33 ug/L at 48-72h suggests potential for recovery; >60 ug/L highly predictive of poor outcome
-
URGENT
-
URGENT
D-dimer (CPT 85379)
DIC screening; ischemia-reperfusion coagulopathy
Normal
URGENT
ROUTINE
-
URGENT
Procalcitonin (CPT 84145)
Differentiate post-arrest SIRS from infection; guide antibiotic decisions
<0.5 ng/mL (elevated common post-arrest without infection)
URGENT
ROUTINE
-
URGENT
Cortisol (AM) (CPT 82533)
Adrenal insufficiency from prolonged shock; critical illness-related corticosteroid insufficiency
>18 ug/dL
-
ROUTINE
-
ROUTINE
TSH (CPT 84443)
Hypothyroidism as contributing factor
Normal
-
ROUTINE
ROUTINE
-
BNP / NT-proBNP (CPT 83880)
Post-arrest myocardial dysfunction severity; volume status
Emergent if STEMI; urgent if no obvious non-cardiac etiology and shockable rhythm (VF/VT). AHA/ILCOR: emergent PCI for STEMI; consider early cath for non-STEMI arrests with shockable rhythm
Identify and treat coronary occlusion as precipitant of arrest
Active bleeding; known anaphylaxis to contrast
STAT
STAT
-
STAT
Continuous EEG (cEEG) (CPT 95700)
Initiate within 12h of ICU admission; detect nonconvulsive seizures (NCSE in 10-30% of comatose post-arrest); monitor for burst-suppression; assess background reactivity for prognostication at >=72h
Background: continuous vs burst-suppression vs suppression; reactivity to stimuli; seizures/NCSE. Highly malignant patterns (suppression, burst-suppression without reactivity) predict poor outcome
None
-
STAT
-
STAT
Echocardiogram (TTE) (CPT 93306)
Within 24h; assess post-arrest myocardial dysfunction (stunned myocardium); EF for hemodynamic management; identify structural cause (HCM, valvular)
Post-arrest EF often 25-40% (usually recovers by 72h); wall motion abnormalities; structural abnormality
Perform at >=72h post-ROSC after rewarming and sedation washout. Bilateral absence of N20 cortical responses is one of the most reliable poor prognostic indicators (FPR <1%)
Bilateral N20 present = good sign. Bilateral N20 absent = poor prognosis (FPR ~0-1% per AAN). N20 amplitude <0.62 uV also predictive
None absolute; requires cooperative technician and reduced electrical interference
-
URGENT
-
URGENT
CT head with quantitative GWR measurement
At 24-48h post-ROSC; measure gray-white matter ratio at basal ganglia level and centrum semiovale
GWR <1.10 at caudate nucleus level at 24-48h predicts poor outcome (FPR <5%). Diffuse sulcal effacement, absent basal cisterns, loss of differentiation
Targeted Temperature Management (TTM) — cooling to 32-36C
IV/External
ALL comatose cardiac arrest survivors (GCS motor <6 after ROSC). TTM2 trial: no difference between 33C vs 36C; both superior to fever. AHA/ILCOR 2020: target 32-36C for at least 24h
32-36C :: external/IV :: continuous x 24h :: Initiate cooling ASAP post-ROSC; use surface (Arctic Sun) or intravascular (Thermogard) cooling; target temperature within 4h; maintain for at least 24h; rewarm at 0.25C/h (avoid >0.5C/h); prevent fever (<37.7C) for at least 72h after ROSC
Active hemorrhage (relative); refractory cardiogenic shock (relative); terminal illness (relative)
Core temperature (esophageal or bladder probe) continuously; shivering assessment (BSAS) q1h; electrolytes (K, Mg, Ca, Phos) q4-6h during cooling; coagulation q12h; skin checks q4h for surface cooling
STAT
STAT
-
STAT
Meperidine (Demerol)
IV
Shivering during TTM (counterproductive; increases metabolic demand and defeats cooling); first-line anti-shivering agent
25-50 mg :: IV :: q4h PRN :: 25-50 mg IV q4h PRN shivering; first-line anti-shivering agent
Shivering scale (BSAS); sedation; respiratory status
-
-
-
STAT
Buspirone
PO/NG
Adjunctive anti-shivering during TTM; lowers shivering threshold by 0.7C
30 mg :: PO :: q8h :: 30 mg PO/NG q8h; lowers shivering threshold by 0.7C
MAOIs
Shivering scale
-
-
-
ROUTINE
Magnesium sulfate
IV
Adjunctive anti-shivering; lowers shivering threshold and seizure threshold
2-4 g :: IV :: bolus then infusion :: 2-4 g IV bolus then 1-2 g/h infusion; target Mg 3-4 mg/dL
Renal failure (accumulation); severe bradycardia
Mg level q4-6h; deep tendon reflexes; HR
-
-
-
STAT
Cisatracurium
IV
Refractory shivering despite first-line measures during TTM; note: obscures clinical exam and must be discontinued well before prognostication
0.15 mg/kg :: IV :: bolus then infusion :: 0.15 mg/kg IV bolus, then 1-3 mcg/kg/min infusion; titrate to train-of-four 1-2/4
Caution in myasthenia gravis
Train-of-four (TOF) q4h; cEEG mandatory when paralyzed (seizures undetectable clinically)
-
-
-
STAT
Norepinephrine
IV
Post-arrest myocardial dysfunction with MAP <65 mmHg; first-line vasopressor for post-arrest shock
0.1-0.5 mcg/kg/min :: IV :: infusion :: Start 0.05-0.1 mcg/kg/min; titrate to MAP >65 (or >80 if signs of cerebral hypoperfusion); max 2 mcg/kg/min
Peripheral line extravasation (central access preferred)
Arterial line BP; MAP; urine output; lactate q4-6h
STAT
STAT
-
STAT
Dobutamine
IV
Post-arrest cardiogenic shock with reduced EF (<30%); augment cardiac output when vasopressors alone insufficient
2.5-20 mcg/kg/min :: IV :: infusion :: Start 2.5 mcg/kg/min; titrate to cardiac output and MAP; consider with echo guidance
LVOT obstruction; severe tachyarrhythmia
HR; BP; cardiac output (echo or PA catheter); arrhythmia
-
-
-
STAT
Vasopressin
IV
Adjunctive vasopressor for refractory hypotension when norepinephrine dose >0.3 mcg/kg/min
0.01-0.04 units/min :: IV :: infusion :: 0.01-0.04 units/min; does not titrate above 0.04
Digital ischemia (relative); peripheral vascular disease
MAP; urine output; peripheral perfusion; serum Na
-
-
-
STAT
Levetiracetam
IV
First-line for post-anoxic seizures and NCSE (common in 10-30% of comatose post-arrest patients); treat all electrographic seizures aggressively
1000-1500 mg :: IV :: BID :: 1000-1500 mg IV load; then 500-1000 mg IV BID; transition to PO when able; no hepatic metabolism; minimal drug interactions
Severe renal impairment (dose adjust for CrCl <30)
cEEG; renal function; seizure recurrence
STAT
STAT
-
STAT
Valproic acid (Depakote)
IV
Second-line for post-anoxic seizures; add if seizures refractory to levetiracetam
20-40 mg/kg :: IV :: load then BID :: 20-40 mg/kg IV load over 15 min (max 3000 mg); then 500 mg IV q12h; target level 50-100 ug/mL
per protocol :: IV :: infusion :: Continuous insulin infusion titrated to BG 140-180; transition to sliding scale when hemodynamically stable and tolerating nutrition
Hypoglycemia risk
BG q1h while on drip; q4-6h on sliding scale; potassium with each BG
STAT
STAT
-
STAT
Mechanical ventilation optimization
-
ALL intubated post-arrest patients; target normoxia and normocapnia
per protocol :: - :: continuous :: Target PaO2 75-100 mmHg (avoid hyperoxia PaO2 >300); PaCO2 35-45 mmHg (avoid hypo/hypercapnia); PEEP as needed
N/A
ABG q4-6h during active TTM; SpO2 continuous; EtCO2 continuous
Sedation during TTM; additional anti-seizure properties; preferred for shorter-acting effect facilitating neurological assessment
5-80 mcg/kg/min :: IV :: infusion :: 5-50 mcg/kg/min; titrate to RASS -4 to -5 during active TTM; wean after rewarming
Propofol infusion syndrome risk (monitor for metabolic acidosis, rhabdomyolysis, hypertriglyceridemia if >48h at high doses >70 mcg/kg/min); egg/soy allergy
Triglycerides q24h; CK if prolonged use; RASS; cEEG
-
-
-
STAT
Fentanyl
IV
Analgesia and sedation during TTM; preferred analgesic during hypothermia (hepatic metabolism reduced)
25-200 mcg/h :: IV :: infusion :: 25-100 mcg/h continuous infusion; titrate to RASS target; bolus 25-50 mcg PRN
Respiratory depression (ventilated patients); severe hepatic impairment
RASS; respiratory rate (if not ventilated); bowel function
-
-
-
STAT
Midazolam
IV
Alternative/adjunctive sedation if propofol contraindicated; anti-seizure properties
0.02-0.1 mg/kg/h :: IV :: infusion :: 0.02-0.1 mg/kg/h continuous; accumulates with prolonged use; prolongs sedation washout (confounder for prognostication)
Severe hepatic impairment; prolonged use delays prognostication
RASS; cEEG; watch for prolonged effect delaying prognostication
-
-
-
STAT
Acetaminophen
IV
Fever prevention and treatment post-TTM; target normothermia (<37.7C) for at least 72h post-ROSC
1000 mg :: IV :: q6h :: 1000 mg IV q6h scheduled (not PRN); max 4g/day
Severe hepatic impairment
Temperature q4h; LFTs
-
STAT
-
STAT
Pantoprazole
IV
GI stress ulcer prophylaxis; post-arrest patients at high risk
40 mg :: IV :: daily :: 40 mg IV daily; transition to PO when tolerating
C. difficile risk with prolonged use
GI symptoms
-
ROUTINE
-
ROUTINE
Enoxaparin
SC
DVT prophylaxis; immobilized comatose patients at high VTE risk; start after active hemorrhage excluded and hemostasis adequate
40 mg :: SC :: daily :: 40 mg SC daily; start 24-48h post-ROSC if no active bleeding
Active hemorrhage; platelet count <50,000; DIC
Platelet count; signs of bleeding; anti-Xa level if renal impairment
-
ROUTINE
-
ROUTINE
Pneumatic compression devices
External
DVT prophylaxis; start IMMEDIATELY in all post-arrest patients
apply bilaterally :: external :: continuous :: Apply bilaterally on admission; maintain continuously when not ambulating
Active DVT; skin breakdown
Skin checks; compliance
STAT
STAT
-
STAT
Clonazepam
PO/NG
Post-anoxic myoclonus (both early status myoclonus and Lance-Adams syndrome); first-line for myoclonus suppression
0.5 mg :: PO :: BID :: Start 0.5 mg PO BID; titrate by 0.5 mg q3d to effect; max 6 mg/day
Severe respiratory depression (non-ventilated); severe hepatic impairment
Sedation; respiratory status; swallowing function
-
ROUTINE
ROUTINE
ROUTINE
Valproic acid (myoclonus)
PO/IV
Post-anoxic myoclonus (adjunctive or alternative to clonazepam)
250 mg :: PO :: BID :: Start 250 mg PO BID; titrate to 500-1000 mg TID; target level 50-100 ug/mL
Hepatic failure; mitochondrial disease; pregnancy
LFTs; ammonia; CBC; drug level
-
ROUTINE
ROUTINE
ROUTINE
Levetiracetam (myoclonus)
PO/IV
Post-anoxic myoclonus (adjunctive; less effective as monotherapy for myoclonus than clonazepam)
500 mg :: PO :: BID :: Start 500 mg PO BID; titrate to 1000-1500 mg BID
Post-anoxic refractory seizures not controlled by levetiracetam and valproic acid
200 mg :: IV :: load then BID :: 200 mg IV load over 15 min; then 100-200 mg IV BID; target level 10-20 ug/mL
PR prolongation >200 ms; second/third-degree heart block; severe hepatic impairment
ECG (PR interval); cardiac rhythm
-
URGENT
-
URGENT
Phenobarbital
IV
Refractory post-anoxic status epilepticus (third-line ASM)
15-20 mg/kg :: IV :: load then daily :: 15-20 mg/kg IV load at 50-75 mg/min; then 1-3 mg/kg/day maintenance; target level 20-40 ug/mL
Severe respiratory depression (intubated patients only); acute intermittent porphyria
Drug level; respiratory status; BP (causes hypotension); sedation
-
-
-
STAT
Midazolam infusion (RSE)
IV
Continuous seizure activity despite two ASMs (refractory status epilepticus protocol)
0.2 mg/kg :: IV :: bolus then infusion :: 0.2 mg/kg IV bolus, then start 0.1 mg/kg/h; titrate q15min by 0.1 mg/kg/h to EEG seizure suppression or burst-suppression; max 2 mg/kg/h
Hemodynamic instability (may worsen)
cEEG mandatory; BP; vasopressor requirements
-
-
-
STAT
Pentobarbital
IV
Super-refractory post-anoxic status epilepticus (when midazolam/propofol infusions fail)
5 mg/kg :: IV :: load then infusion :: 5 mg/kg IV load over 1h (may repeat 5 mg/kg boluses); maintenance 1-5 mg/kg/h; titrate to burst-suppression on cEEG
Secondary prevention of sudden cardiac death in survivors with cardiac etiology and EF <=35% (or per electrophysiology study); typically implanted before discharge or at 40 days post-MI
N/A :: Procedure :: once :: Per cardiology/electrophysiology; ICD vs S-ICD per anatomy
Cardiac workup complete; EF assessment; electrophysiology study if indicated; shared decision-making
Active infection; terminal illness with <1yr life expectancy
Neurology/neurocritical care consult for neuroprognostication guidance and seizure management in all comatose post-arrest patients
STAT
STAT
-
STAT
Cardiology consult for coronary evaluation, post-arrest myocardial dysfunction management, and arrhythmia workup
STAT
STAT
ROUTINE
STAT
Electrophysiology consult for ICD evaluation in cardiac arrest survivors with arrhythmic etiology
-
ROUTINE
ROUTINE
-
Palliative care consult for goals of care discussion and family support when neuroprognostication suggests poor outcome
-
URGENT
-
URGENT
Physical therapy for early mobilization protocol when neurologically and hemodynamically stable; passive range of motion to prevent contractures in comatose patients
-
URGENT
ROUTINE
URGENT
Occupational therapy for ADL assessment, cognitive rehabilitation, and adaptive equipment in ABI survivors
-
URGENT
ROUTINE
URGENT
Speech-language pathology for swallow evaluation (high aspiration risk in ABI survivors), communication assessment, and cognitive-linguistic rehabilitation
-
URGENT
ROUTINE
URGENT
Neuropsychology for formal cognitive assessment in ABI survivors at 3-6 months post-injury to identify specific deficits and guide rehabilitation
-
-
ROUTINE
-
Rehabilitation medicine (physiatry) for comprehensive rehabilitation planning and disposition (acute rehab vs skilled nursing)
-
ROUTINE
ROUTINE
-
Social work for family support, advance directive assistance, guardianship if needed, and community resource coordination
-
ROUTINE
ROUTINE
ROUTINE
Chaplain/spiritual care for spiritual support for patient family during critical illness and end-of-life discussions
-
ROUTINE
-
ROUTINE
Organ procurement organization (OPO) notification when brain death or withdrawal of life-sustaining treatment being discussed; federal requirement in most jurisdictions
-
ROUTINE
-
ROUTINE
Psychiatry consult for post-cardiac arrest anxiety, PTSD, depression in survivors who regain consciousness
Explain that anoxic brain injury occurs because the brain was deprived of oxygen during cardiac arrest and that recovery is unpredictable in the first 72 hours
STAT
ROUTINE
ROUTINE
STAT
Reassure family that targeted temperature management (cooling) is a standard evidence-based treatment and that the patient appears deeply sedated because of medications and cooling, not necessarily because of brain injury severity
STAT
ROUTINE
-
STAT
Explain that formal neuroprognostication will not occur until at least 72 hours after rewarming because sedation and hypothermia confound the neurological exam
-
ROUTINE
-
ROUTINE
Inform family that neuroprognostication uses multiple tests together (exam, EEG, SSEP, MRI, blood tests) and that no single test alone determines outcome
-
ROUTINE
-
ROUTINE
If poor prognosis confirmed through multimodal testing, discuss goals of care including comfort care, withdrawal of life-sustaining treatment, and organ donation in a compassionate and unhurried manner
-
ROUTINE
-
ROUTINE
For survivors: explain that recovery from anoxic brain injury is a prolonged process (months to years); cognitive, emotional, and physical deficits are common; and rehabilitation is essential
-
ROUTINE
ROUTINE
ROUTINE
For survivors: report immediately if new seizures (shaking, staring, confusion), worsening weakness, difficulty swallowing, or significant mood changes occur as these may indicate complications requiring treatment adjustment
-
ROUTINE
ROUTINE
ROUTINE
For survivors: do not drive until formally cleared by neurology due to risk of seizures and cognitive impairment following anoxic brain injury
-
ROUTINE
ROUTINE
-
Provide written information about cardiac arrest survivors support groups and brain injury advocacy organizations (Brain Injury Association of America, Sudden Cardiac Arrest Foundation)
ALL comatose cardiac arrest survivors require ICU admission for: TTM, cEEG, hemodynamic monitoring, mechanical ventilation, neuroprognostication at >=72h after rewarming
Remain in ICU
Ongoing TTM or rewarming phase; hemodynamic instability requiring vasopressors; active seizures; mechanical ventilation; pending formal neuroprognostication
Step down to floor (monitored bed)
Completed TTM and rewarming; hemodynamically stable off vasopressors; no active seizures; extubated with adequate airway; neuroprognostication suggests potential recovery; awaiting rehabilitation placement
Transfer to acute inpatient rehabilitation
Following commands consistently; medically stable; can tolerate 3 hours/day of therapy; motivated for rehabilitation; functional deficits amenable to rehabilitation interventions
Transfer to skilled nursing facility (SNF)
Unable to tolerate 3h/day of rehabilitation therapy; chronic disorders of consciousness (vegetative or minimally conscious state) requiring ongoing medical management; tracheostomy/PEG care
Transfer to long-term acute care (LTAC)
Requires prolonged ventilator weaning; ongoing complex medical needs; not yet stable enough for SNF or rehabilitation
Discharge home
Alert, communicating; ambulatory or safe with home support; seizures controlled; cardiac workup complete; medications reconciled; follow-up arranged; home AED placed if indicated
Comfort care / withdrawal of life-sustaining treatment
Multimodal neuroprognostication at >=72h post-rewarming confirms poor outcome by at least 2 independent modalities (exam, EEG, SSEP, MRI, NSE); family informed and goals of care aligned; palliative care involved
Brain death evaluation
Clinical suspicion of brain death (absent brainstem reflexes, no respiratory drive); proceed with formal brain death protocol (see Brain Death Evaluation template)
Organ donation consideration
When brain death confirmed or withdrawal of life-sustaining treatment planned; OPO notified per federal requirement; family approached by OPO designated requestor
Ruijter et al. JAMA Neurology 2022 (TELSTAR trial) — aggressive vs standard treatment of electrographic status epilepticus: no difference in primary outcome; treat clinical and electrographic seizures
cEEG monitoring recommended for all comatose post-arrest patients
Indeterminate: Discordant results or only 1 modality abnormal; continue observation, repeat testing, consider additional modalities
Potentially favorable: Improving clinical exam, present N20 on SSEP, continuous reactive EEG background, normal or mildly elevated NSE
CRITICAL REMINDERS:
- No single test is sufficient to declare poor prognosis
- Always use at least 2 concordant modalities from different categories
- Account for ALL confounders (sedation, temperature, metabolic, NMBAs)
- Self-fulfilling prophecy: premature WLST biases outcome literature — allow adequate time
- Some patients with early myoclonus make meaningful recovery; myoclonus alone is NOT sufficient for poor prognostication
APPENDIX B: TARGETED TEMPERATURE MANAGEMENT (TTM) PROTOCOL¶
Initiation Phase (Target: Reach Goal Temperature Within 4 Hours)¶
Step
Action
Details
1
Select target temperature
32-36C (based on institutional protocol; TTM2 trial supports 36C with strict fever prevention)
2
Initiate cooling
Surface: Arctic Sun, cooling blankets. Intravascular: Thermogard XP, CoolGard. Cold saline (4C, 30 mL/kg) NOT recommended as sole cooling method (RINSE trial: no benefit, possible harm)
3
Insert temperature probe
Esophageal (most accurate) or bladder catheter with temp probe
4
Start anti-shivering protocol
Meperidine 25-50 mg IV PRN; buspirone 30 mg q8h; Mg infusion; escalate to NMBAs if refractory
5
Order cEEG
Mandatory; seizures undetectable clinically in sedated/paralyzed patients
6
Check electrolytes
K, Mg, Ca, Phos q4-6h (hypothermia shifts K intracellularly; hypokalemia risk)
Maintenance Phase (24-48 Hours at Target Temperature)¶
Parameter
Target
Action
Temperature
Within 0.5C of target
Adjust cooling device; check probe position
Potassium
4.0-4.5 mEq/L
Aggressive replacement; caution — K will rise during rewarming
0.25C/hour (NEVER >0.5C/hour); rapid rewarming associated with rebound cerebral edema, ICP elevation, and rebound hyperthermia
Duration
12-16h from 33C to 37C; 4-8h from 36C to 37C
Potassium
Reduce replacement during rewarming; K rises as it shifts extracellularly; risk of HYPERKALEMIA
Post-rewarming
Maintain normothermia (<37.7C) for at least 72h post-ROSC using acetaminophen and cooling devices
APPENDIX C: MYOCLONUS CLASSIFICATION IN ANOXIC BRAIN INJURY¶
Type
Timing
Features
Prognosis
Early status myoclonus
Within 24-72h post-arrest
Generalized, continuous or near-continuous myoclonic jerking; often involves face, limbs, axial muscles; typically in deeply comatose patients; may be stimulus-sensitive
Generally associated with POOR outcome; however, NOT invariably fatal — some survivors with good recovery reported (especially if other prognostic indicators are favorable)
Acute cortical myoclonus
Within 72h
Focal or multifocal; stimulus-sensitive; cortical origin on EEG (time-locked cortical discharges)
Variable; may respond to ASMs; use multimodal prognostication
Lance-Adams syndrome
Days to weeks after arrest (during recovery)
Action myoclonus in CONSCIOUS patients; triggered by voluntary movements; intention myoclonus; may be severely disabling but patient is AWAKE
GOOD prognosis for survival (patient is conscious); may improve with clonazepam, valproic acid, levetiracetam; long-term disability varies
Subcortical/reticular myoclonus
Variable
Generalized; no cortical correlate on EEG; brainstem origin
Variable
KEY PRINCIPLE: Myoclonus alone is NEVER sufficient for prognostication. Always integrate with multimodal assessment. The distinction between status myoclonus (continuous, generalized, in comatose patient) vs Lance-Adams (action myoclonus in awake patient) has critical prognostic implications.
v1.1 (January 30, 2026)
- Fixed column order in all lab tables (1A, 1B, 1C) to place venue columns (ED/HOSP/OPD/ICU) as last 4 columns per style guide
- Fixed column order in all imaging tables (2A, 2B, 2C) to place venue columns as last 4 columns per style guide
- Fixed column order in Section 6 Monitoring to place venue columns as last 4 columns per style guide
- Standardized structured dosing format (dose :: route :: frequency :: instructions) across all treatment tables (3A, 3B, 3C, 3D)
- Added OPD coverage for follow-up labs (CBC, CMP, glucose, Mg, Ca, Phos) in Section 1A for survivor clinic visits
- Added ICU column to Sections 4B and 4C for setting consistency
- Updated section dividers to Unicode box-drawing characters
- Added Pre-Treatment Requirements to Section 3D medications (amantadine, sertraline, methylphenidate, modafinil, baclofen, tizanidine, botox)
- Cleaned up treatment names to remove redundant section headers (e.g., "Shivering management:" prefix removed)
- Fixed pneumatic compression devices Route column (was "-", now "External")
- Added REVISED date to header metadata
- Updated version to 1.1
v1.0 (January 30, 2026)
- Initial template creation
- Comprehensive post-cardiac arrest care bundle including TTM protocol
- Multimodal neuroprognostication algorithm (clinical exam, EEG, SSEP, MRI, NSE, CT GWR)
- Confounder identification and elimination checklist
- Myoclonus classification (early status myoclonus vs Lance-Adams syndrome)
- Rehabilitation pathway for survivors (amantadine, spasticity management, cognitive rehab)
- Seizure management protocol including refractory status epilepticus
- Family communication and goals of care guidance
- Organ donation considerations
- All citations include PubMed links where available