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Brain Death Current Consensus

The document discusses the history and criteria for determining brain death, including the absence of brainstem function and cerebral cortex activity, as well as apnea testing to confirm the lack of spontaneous breathing. It outlines the neurological examination and confirmatory tests used to diagnose brain death while distinguishing it from other conditions like persistent vegetative state.

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Ni Putu Ripna Oktaviani
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18 views

Brain Death Current Consensus

The document discusses the history and criteria for determining brain death, including the absence of brainstem function and cerebral cortex activity, as well as apnea testing to confirm the lack of spontaneous breathing. It outlines the neurological examination and confirmatory tests used to diagnose brain death while distinguishing it from other conditions like persistent vegetative state.

Uploaded by

Ni Putu Ripna Oktaviani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Brain Death

Anatomy and
Physiology
Historical Perspective

Prior to the advent of mechanical


respiration, death was defined as
the cessation of circulation and
breathing
Historical Perspective
1959 Coma depasse Mollaret and Goulon

1968 Irreversible Coma/Brain Death Harvard


Medical School Ad Hoc Committee

1981 Uniform Determination of Death Act -


Presidents Commission for the Study of Ethical
Problems in Medicine

1994 American Academy of Neurology Guidelines


for the determination of Brain Death

2005 NYS Guidelines for Determining Brain Death


Brain Death Current
Consensus

Absent Cerebral Function

Absent Brainstem Function

Apnea
Normal Brain Anatomy
Normal Brain Anatomy

Cerebral Cortex

Reticular
Activating
Brain Stem System
Cerebral Cortex
Cognition
Voluntary
Movement
Sensation
Brain Stem
Brain Stem

Midbrain
Cranial Nerve III
pupillary
function
eye movement
Brain Stem

Pons
Cranial Nerves IV, V, VI
conjugate eye
movement
corneal reflex
Brain Stem

Medulla
Cranial Nerves IX, X
Pharyngeal (Gag)
Reflex
Tracheal (Cough)
Reflex
Respiration
Reticular Activating
System

Receives multiple
sensory inputs

Mediates
wakefulness
Causes of Brain Death

Normal Cerebral Anoxia


Causes of Brain Death

Normal Cerebral Hemorrhage


Causes of Brain Death

Normal Subarachnoid
Hemorrhage
Causes of Brain Death

Normal Trauma
Causes of Brain Death

Normal Meningitis
Mechanism of Cerebral
Death

Neuronal Injury Neuronal Swelling

ICP>MAP is
incompatible
with life

Decreased Intracranial Increased Intracranial


Blood Flow Pressure
Conditions Distinct
From Brain Death

Persistent Vegetative State

Locked-in Syndrome

Minimally Responsive State


Persistent Vegetative
State

Normal Sleep-Wake Cycles

No Response to Environmental
Stimuli

Diffuse Brain Injury with


Preservation of Brain Stem Function
Locked-in Syndrome

Ventral Pontine
Infarct
Complete Paralysis

Preserved
Consciousness

Preserved Eye
Movement
Minimally Responsive
State Static Encephalopathy

Diffuse or Multi-Focal Brain Injury

Preserved Brain Stem Function

Variable Interaction with


Environmental Stimuli
Brain Death
Neurological
Examination
Clinical Prerequisites:

Known Irreversible Cause

Exclusion of Potentially Reversible


Conditions
Drug Intoxication or Poisoning
Electrolyte or Acid-Base Imbalance
Endocrine Disturbances

Core Body temperature > 32 C


Brain Death
Neurological
Examination
Coma

Absent Brain Stem Reflexes

Apnea
Coma

No Response to Noxious Stimuli

Nail Bed Pressure

Sternal Rub

Supra-Orbital Ridge Pressure


Absence of Brain Stem
Reflexes
Pupillary Reflex

Eye Movements

Facial Sensation and Motor Response

Pharyngeal (Gag) Reflex

Tracheal (Cough) Reflex


Pupillary Reflex

Pupils dilated with no constriction to bright


light
Eye Movements

Occulo-Cephalic
Response
Dolls Eyes Maneuver
Eye Movements

Oculo-Vestibular Response
Cold Caloric Testing
Facial Sensation and
Motor Response
Corneal Reflex

Jaw Reflex
Grimace to Supraorbital or
Temporo-Mandibular Pressure
Apnea Testing

Prerequisites

Core Body Temperature > 32 C

Systolic Blood Pressure 90 mm


Hg

Normal Electrolytes

Normal PCO2
Apnea Testing

1. Pre-Oxygenation
100% Oxygen via Tracheal Cannula
PO2 = 200 mm Hg

2. Monitor PCO2 and PO2 with pulse oximetry


3. Disconnect Ventilator
4. Observe for Respiratory Movement until
PCO2 = 60 mm Hg
5. Discontinue Testing if BP < 90, PO2
saturation decreases, or cardiac dysrhythmia
observed
Confounding Clinical
Conditions
Facial Trauma

Pupillary Abnormalities

CNS Sedatives or Neuromuscular


Blockers

Hepatic Failure

Pulmonary Disease
Observations
Compatible with Brain
Death
Sweating, Blushing

Deep Tendon Reflexes

Spontaneous Spinal Reflexes- Triple


Flexion

Babinski Sign
Confirmatory Testing

Recommended when the proximate


cause of coma is not known or when
confounding clinical conditions limit
the clinical examination
Confirmatory Testing
EE
G

Normal Electrocerebral
Confirmatory Testing

Cerebral
Angiography

Normal No Intracranial
Confirmatory Testing

Technetium-99 Isotope Brain Scan


Confirmatory Testing

MR- Angiography
Confirmatory Testing

Transcranial
Ultrasonography
Confirmatory Testing

Somatosensory Evoked Potentials


Concern for man and his fate must
always form the chief interest of all
technical endeavors. Never forget this in
the midst of your diagrams and
equations.

Albert Einstein

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