Abstract
Objective: We previously demonstrated feasibility of prehospital pupillometry to quantify/qualify the pupillary light reflex (PLR) during resuscitation as a potential neurophysiological marker to guide efforts & provide early neuroprognostication. We now report on the full cohort. Hypothesis: PLR during resuscitation is associated with ROSC & neurologic outcome (following commands [FC]; mRS 0-3 & CPC 1-2) at hospital discharge. Methods: Prospective, observational cohort in which we deployed hand-held pupillometers (NeurOptics, Inc) to EMS-treated OHCA subjects for serial recordings during pulse checks until ROSC, termination, or hospital arrival. We categorized PLR as normal/abnormal/absent with the Neurologic Pupillary Index (NPi), a continuous scale (0-5) combining facets of PLR (e.g. % change, velocity, latency). We abstracted patient data from prehospital & hospital records, tabulated data, estimated test performance, and performed ROC analysis for best NPi & outcomes. Results: From 2/14 - 4/15, 186 subjects were enrolled (61 ± 20 years, 58% male, 41% witnessed, 43% bystander CPR, 25% shockable rhythm). Most (92%) received epi (median 5mg), 12% atropine (median 1mg), 37% defibrillated (median 3.5 attempts). At submission, 173 (96%) had complete follow-up data (44% transported to hospital, 31% ROSC). Of 39 (22%) subjects admitted to hospital (76% hypothermia, 26% cardiac catheterization), 7 survived to discharge with 6 FC & 5 mRS 0-3. Of 1,552 readings attempted (median 7/subject), 39% had usable data & 74% subjects had ≥1 usable reading, Only 15% subjects had PLR during resuscitation. Best NPi > 4.0 classified 92% of FC (LR+ 17; overall AUC 0.69), whereas best NPi > 4.5 classified 98% favorable mRS & CPC (LR+ 67; overall AUC 0.70). Conclusion: A minority of subjects had detectable PLR. Normal PLR was rare, but had high overall classification accuracy for FC, & strong likelihood ratios for ROSC & neurologic outcome. Best NPi had fair test performance by AUC.
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