Dr.  Cohen
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  • 1. Brain Death Anatomy and Physiology
    • Joel S. Cohen, M.D.
    • Associate Professor of Clinical Neurology
    • Albert Einstein College of Medicine
  • 2. Historical Perspective
    • Prior to the advent of mechanical respiration, death was defined as the cessation of circulation and breathing
  • 3. Historical Perspective
    • 1959 Coma de’passe’ Mollaret and Goulon
    • 1968 Irreversible Coma/Brain Death Harvard Medical School Ad Hoc Committee
    • 1981 Uniform Determination of Death Act - President’s 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
  • 4. Brain Death Current Consensus
    • Absent Cerebral Function
    • Absent Brainstem Function
    • Apnea
  • 5. Normal Brain Anatomy
  • 6. Normal Brain Anatomy Cerebral Cortex Brain Stem Reticular Activating System
  • 7. Cerebral Cortex
    • Cognition
    • Voluntary Movement
    • Sensation
  • 8. Brain Stem
  • 9. Brain Stem
    • Midbrain
      • Cranial Nerve III
        • pupillary function
        • eye movement
  • 10. Brain Stem
    • Pons
    • Cranial Nerves IV, V, VI
      • conjugate eye movement
      • corneal reflex
  • 11. Brain Stem
    • Medulla
    • Cranial Nerves IX, X
        • Pharyngeal (Gag) Reflex
        • Tracheal (Cough) Reflex
    • Respiration
  • 12. Reticular Activating System
    • Receives multiple sensory inputs
    • Mediates wakefulness
  • 13. Causes of Brain Death Normal Cerebral Anoxia
  • 14. Causes of Brain Death Normal Cerebral Hemorrhage
  • 15. Causes of Brain Death Normal Subarachnoid Hemorrhage
  • 16. Causes of Brain Death Normal Trauma
  • 17. Causes of Brain Death Normal Meningitis
  • 18. Mechanism of Cerebral Death Increased Intracranial Pressure ICP>MAP is incompatible with life Neuronal Injury Decreased Intracranial Blood Flow Neuronal Swelling
  • 19. Conditions Distinct From Brain Death
    • Persistent Vegetative State
    • Locked-in Syndrome
    • Minimally Responsive State
  • 20. Persistent Vegetative State
    • Normal Sleep-Wake Cycles
    • No Response to Environmental Stimuli
    • Diffuse Brain Injury with Preservation of Brain Stem Function
  • 21. Locked-in Syndrome Ventral Pontine Infarct
    • Complete Paralysis
    • Preserved Consciousness
    • Preserved Eye Movement
  • 22. Minimally Responsive State
    • Diffuse or Multi-Focal Brain Injury
    • Preserved Brain Stem Function
    • Variable Interaction with Environmental Stimuli
    Static Encephalopathy
  • 23. 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
  • 24. Brain Death Neurological Examination
    • Coma
    • Absent Brain Stem Reflexes
    • Apnea
  • 25. Coma
    • No Response to Noxious Stimuli
        • Nail Bed Pressure
        • Sternal Rub
        • Supra-Orbital Ridge Pressure
  • 26. Absence of Brain Stem Reflexes
    • Pupillary Reflex
    • Eye Movements
    • Facial Sensation and Motor Response
    • Pharyngeal (Gag) Reflex
    • Tracheal (Cough) Reflex
  • 27. Pupillary Reflex Pupils dilated with no constriction to bright light
  • 28. Eye Movements Occulo-Cephalic Response “ Doll’s Eyes Maneuver”
  • 29. Eye Movements Oculo-Vestibular Response “ Cold Caloric Testing”
  • 30. Facial Sensation and Motor Response
    • Corneal Reflex
    • Jaw Reflex
    • Grimace to Supraorbital or
    • Temporo-Mandibular Pressure
  • 31. Apnea Testing
    • Prerequisites
        • Core Body Temperature > 32° C
        • Systolic Blood Pressure ≥ 90 mm Hg
        • Normal Electrolytes
        • Normal PCO2
  • 32. 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
  • 33. Confounding Clinical Conditions
    • Facial Trauma
    • Pupillary Abnormalities
    • CNS Sedatives or Neuromuscular Blockers
    • Hepatic Failure
    • Pulmonary Disease
  • 34. Observations Compatible with Brain Death
    • Sweating, Blushing
    • Deep Tendon Reflexes
    • Spontaneous Spinal Reflexes- Triple Flexion
    • Babinski Sign
  • 35. Confirmatory Testing
    • Recommended when the proximate cause of coma is not known or when confounding clinical conditions limit the clinical examination
  • 36. Confirmatory Testing EEG Normal Electrocerebral Silence
  • 37. Confirmatory Testing
    • Cerebral Angiography
    Normal No Intracranial Flow
  • 38. Confirmatory Testing
    • Technetium-99 Isotope Brain Scan
  • 39. Confirmatory Testing
    • MR- Angiography
  • 40. Confirmatory Testing Transcranial Ultrasonography
  • 41. Confirmatory Testing
    • Somatosensory Evoked Potentials
  • 42.
    • 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