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Dr (Brig)  YD Singh MBBS, MD, FIACM, DIT Professor (Internal Medicine) SKN Medical College & Gen Hospital Pune 411 041
Brain Death <ul><li>Death: An Introduction </li></ul><ul><ul><li>Genesis of Brain Death concept ? </li></ul></ul><ul><li>D...
Normal Brain Anatomy 25 September 2011 Dr (Brig) YD Singh Cerebral Cortex Brain Stem Reticular Activating System Receives ...
Two Dimensions of Consciousness 25 September 2011 Dr (Brig) YD Singh
Cerebral Cortex: Function 25 September 2011 Dr (Brig) YD Singh <ul><li>Cognition </li></ul><ul><li>Voluntary Movement </li...
Brain Stem : Functions 25 September 2011 Dr (Brig) YD Singh <ul><li>Midbrain </li></ul><ul><ul><li>Cranial Nerve III </li>...
Brain Stem : Functions 25 September 2011 Dr (Brig) YD Singh <ul><li>Pons </li></ul><ul><li>Cranial Nerve IV, V, VI </li></...
Brain Stem : Functions 25 September 2011 Dr (Brig) YD Singh <ul><li>Medulla </li></ul><ul><li>Cranial Nerve IX, X </li></u...
Death : Definition <ul><li>Thanatology  </li></ul><ul><ul><li>Branch of science dealing with study of death </li></ul></ul...
Brain Death : USA <ul><li>Uniform Determination of Death Act 1981 </li></ul><ul><ul><li>An individual who has sustained ei...
Brain Death : USA <ul><li>The American Academy of Neurology (1995) </li></ul><ul><ul><li>Published practice parameter to d...
Death Definition : Indian Laws <ul><li>Registration of Births & Deaths Act 1969 </li></ul><ul><ul><li>Defines death as per...
Brain Death : Indian Laws <ul><li>Transplantation of Human Organs act, 1994 </li></ul><ul><ul><li>“ Deceased person&quot; ...
Brain Death : India <ul><li>Transplantation of Human Organs act, 1994 </li></ul><ul><ul><li>Brain death needs to be certif...
Brain Death : India <ul><li>Transplantation of Human Organs act, 1994 </li></ul><ul><li>Highlights: </li></ul><ul><ul><li>...
Causes: Brain Death 25 September 2011 Dr (Brig) YD Singh Normal Cerebral  Anoxia
Causes: Brain Death 25 September 2011 Dr (Brig) YD Singh Normal Cerebral  Haemorrhage
Causes: Brain Death 25 September 2011 Dr (Brig) YD Singh Normal Cerebral  Trauma
Brain Death : Mechanism 25 September 2011 Dr (Brig) YD Singh Neuronal Injury  Decreased Intracranial  Blood Flow  Neuronal...
Brain Death: Diagnosis <ul><li>04 Steps to diagnosis </li></ul><ul><li>(1) Clinical Evaluation (Prerequisites) </li></ul><...
Brain Death: Diagnosis <ul><li>04 Steps to diagnosis </li></ul><ul><li>(2) Clinical Evaluation (Neuro assessment) </li></u...
Brain Death Neurologic Examination <ul><li>COMA </li></ul><ul><li>Establish No response to noxious stimulus </li></ul><ul>...
Brain Death Neurologic Examination <ul><li>Absent Brain Stem Reflexes </li></ul><ul><li>Pupillary Reflex (absent) </li></u...
Brain Death Neurologic Examination 25 September 2011 Dr (Brig) YD Singh Pupils dilated with no constriction to bright light
Brain Death Neurologic Examination <ul><li>Occulo Cephalic Response </li></ul><ul><li>  (No Dolls Eye Movements) </li></ul...
Brain Death Neurologic Examination 25 September 2011 Dr (Brig) YD Singh Occulo-Vestibular Response “ Cold Caloric Testing”...
Brain Death Neurologic Examination 25 September 2011 Dr (Brig) YD Singh Facial Sensations & Motor  Response <ul><li>Absent...
Brain Death : Apnoea Test <ul><li>Pre-requisites </li></ul><ul><ul><li>Body Temperature > 36° C </li></ul></ul><ul><ul><li...
Brain Death : Apnoea Test <ul><li>Reduce Ventilation frequency to 10/min </li></ul><ul><li>Reduce PEEP to 5 Cm H2O </li></...
Brain Death : Apnoea Test <ul><li>Discontinue Testing </li></ul><ul><ul><li>If BP drops to < 90 mm Hg </li></ul></ul><ul><...
Brain Death Ancillary Confirmatory Testing <ul><li>Recommended when  </li></ul><ul><ul><li>Proximate cause of coma is not ...
Brain Death Confirmatory Testing 25 September 2011 Dr (Brig) YD Singh Electro-Cerebral Silence Normal EEG
Brain Death Confirmatory Testing 25 September 2011 Dr (Brig) YD Singh No Intra- Cranial Flow Normal Cerebral Angiography
PET Glucose Metabolism Studies 25 September 2011 Dr (Brig) YD Singh “ Hollow-skull sign”  of brain death Cerebral metaboli...
Dynamic Nuclear Brain Scan  25 September 2011 Dr (Brig) YD Singh “ Hollow-skull sign” of brain death NEJM 2001;344:1215-1221
Conditions Distinct from Brain Death <ul><li>Coma </li></ul><ul><li>Persistent Vegetative State </li></ul><ul><li>Locked i...
Coma <ul><li>It is a sleeplike state from which patient cannot be aroused </li></ul><ul><ul><li>It is sleep like because <...
Persistent Vegetative state <ul><li>Patient out of Coma and appears awake </li></ul><ul><ul><li>Follows Normal Sleep-Wake ...
Persistent Vegetative state 25 September 2011 Dr (Brig) YD Singh Aruna Ramachandra Shanbag Mumbai
Locked in Syndrome 25 September 2011 Dr (Brig) YD Singh Ventral Pontine Infarct <ul><li>Complete Paralysis </li></ul><ul><...
Brain Death Conclusions <ul><li>In the U.S., Brain death is considered death for all purposes </li></ul><ul><li>In India B...
Brain Death Conclusions <ul><li>PVS Patient is not dead </li></ul><ul><ul><li>In a state of wakefulness without awareness ...
Brain Death : Present Status <ul><li>Hippocrates said this long ago </li></ul><ul><li>(The Hippocratic Corpus) </li></ul><...
Thanks !! 25 September 2011 Dr (Brig) YD Singh
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Brain death Present status YDS

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Discusses the present status of Brain Death Concept in Indian Context.

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Transcript of "Brain death Present status YDS"

  1. 1. Dr (Brig) YD Singh MBBS, MD, FIACM, DIT Professor (Internal Medicine) SKN Medical College & Gen Hospital Pune 411 041
  2. 2. Brain Death <ul><li>Death: An Introduction </li></ul><ul><ul><li>Genesis of Brain Death concept ? </li></ul></ul><ul><li>Death definition under Indian Laws </li></ul><ul><li>What is brain death? </li></ul><ul><ul><li>Scene in USA </li></ul></ul><ul><ul><li>Scene in India </li></ul></ul><ul><li>Causes of Brain Death </li></ul><ul><li>Brain Death Diagnosis </li></ul><ul><li>Other Related Terms </li></ul><ul><ul><li>Permanent Vegetative State </li></ul></ul><ul><ul><li>Locked in Syndrome </li></ul></ul><ul><ul><li>Coma </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  3. 3. Normal Brain Anatomy 25 September 2011 Dr (Brig) YD Singh Cerebral Cortex Brain Stem Reticular Activating System Receives multiple sensory inputs & Mediates Consciousness (wakefulness)
  4. 4. Two Dimensions of Consciousness 25 September 2011 Dr (Brig) YD Singh
  5. 5. Cerebral Cortex: Function 25 September 2011 Dr (Brig) YD Singh <ul><li>Cognition </li></ul><ul><li>Voluntary Movement </li></ul><ul><li>Sensation </li></ul>
  6. 6. Brain Stem : Functions 25 September 2011 Dr (Brig) YD Singh <ul><li>Midbrain </li></ul><ul><ul><li>Cranial Nerve III </li></ul></ul><ul><ul><ul><li>Pupillary Function </li></ul></ul></ul><ul><ul><ul><li>Eye Movement </li></ul></ul></ul>
  7. 7. Brain Stem : Functions 25 September 2011 Dr (Brig) YD Singh <ul><li>Pons </li></ul><ul><li>Cranial Nerve IV, V, VI </li></ul><ul><li>Conjugate Eye Movement </li></ul><ul><li>Corneal Reflex </li></ul>
  8. 8. Brain Stem : Functions 25 September 2011 Dr (Brig) YD Singh <ul><li>Medulla </li></ul><ul><li>Cranial Nerve IX, X </li></ul><ul><li>Pharyngeal (Gag) Reflex </li></ul><ul><li>Tracheal (Cough) Reflex </li></ul><ul><li>Respiration </li></ul>
  9. 9. Death : Definition <ul><li>Thanatology </li></ul><ul><ul><li>Branch of science dealing with study of death </li></ul></ul><ul><li>Death is the complete and irreversible stoppage of </li></ul><ul><ul><li>Circulation </li></ul></ul><ul><ul><li>Respiration </li></ul></ul><ul><ul><li>Brain function (Tripod of life) </li></ul></ul><ul><ul><ul><li>As long as oxygenated blood reaches brain stem, Life exists …. </li></ul></ul></ul><ul><li>Mechanical Ventilator use in ICU </li></ul><ul><ul><li>Brought concept of “Brain Death” </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  10. 10. Brain Death : USA <ul><li>Uniform Determination of Death Act 1981 </li></ul><ul><ul><li>An individual who has sustained either </li></ul></ul><ul><ul><ul><li>Irreversible cessation of circulatory & respiratory functions, or </li></ul></ul></ul><ul><ul><ul><li>Irreversible cessation of all functions of the entire brain, including the brain stem, is dead. </li></ul></ul></ul><ul><ul><li>A determination of death must be made with accepted medical standards . </li></ul></ul><ul><ul><li>The Act did not define the accepted medical standards </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  11. 11. Brain Death : USA <ul><li>The American Academy of Neurology (1995) </li></ul><ul><ul><li>Published practice parameter to delineate medical standards for the determination of brain death (These are accepted world wide) </li></ul></ul><ul><li>3 clinical findings necessary to confirm irreversible cessation of all functions of the entire brain, including brain stem </li></ul><ul><ul><li>Coma (with a known cause) </li></ul></ul><ul><ul><li>Absence of brainstem reflexes </li></ul></ul><ul><ul><li>Apnoea </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  12. 12. Death Definition : Indian Laws <ul><li>Registration of Births & Deaths Act 1969 </li></ul><ul><ul><li>Defines death as permanent disappearance of all evidence of life at any time after live-birth has taken place. {Section 2 (1)(b) } </li></ul></ul><ul><li>Transplantation of Human Organs Act 1994 </li></ul><ul><ul><li>“ Brain-Stem death&quot; Means the stage at which all functions of the brain-stem have permanently and irreversibly ceased and is so certified under sub-section (6) of section 3 </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  13. 13. Brain Death : Indian Laws <ul><li>Transplantation of Human Organs act, 1994 </li></ul><ul><ul><li>“ Deceased person&quot; </li></ul></ul><ul><ul><ul><li>Means a person in whom permanent disappearance of all evidence of life occurs, by reason of brain-stem death or in a cardiopulmonary sense, at any time after live birth has taken place { Section 2(e) } </li></ul></ul></ul>25 September 2011 Dr (Brig) YD Singh
  14. 14. Brain Death : India <ul><li>Transplantation of Human Organs act, 1994 </li></ul><ul><ul><li>Brain death needs to be certified by a board of doctors consisting of : </li></ul></ul><ul><ul><ul><li>Registered Medical Practitioner (RMP) in charge of hospital where brain death has occurred </li></ul></ul></ul><ul><ul><ul><li>An independent RMP – a specialist </li></ul></ul></ul><ul><ul><ul><li>A Neurologist / Neurosurgeon nominated by panel </li></ul></ul></ul><ul><ul><ul><li>RMP treating the patient </li></ul></ul></ul><ul><ul><li>The patient must be examined by team of doctors at least twice with a reasonable gap of time in between (at least 6 hours) </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  15. 15. Brain Death : India <ul><li>Transplantation of Human Organs act, 1994 </li></ul><ul><li>Highlights: </li></ul><ul><ul><li>Statutary sanction to the Brain Death Concept </li></ul></ul><ul><ul><li>Regulation of Removal, Storage and Transplantation of human organs for therapeutic purposes </li></ul></ul><ul><ul><li>Commercial dealings in human organs prevented </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  16. 16. Causes: Brain Death 25 September 2011 Dr (Brig) YD Singh Normal Cerebral Anoxia
  17. 17. Causes: Brain Death 25 September 2011 Dr (Brig) YD Singh Normal Cerebral Haemorrhage
  18. 18. Causes: Brain Death 25 September 2011 Dr (Brig) YD Singh Normal Cerebral Trauma
  19. 19. Brain Death : Mechanism 25 September 2011 Dr (Brig) YD Singh Neuronal Injury Decreased Intracranial Blood Flow Neuronal Swelling Increased Intracranial Pressure ICP > MAP is incompatible with life
  20. 20. Brain Death: Diagnosis <ul><li>04 Steps to diagnosis </li></ul><ul><li>(1) Clinical Evaluation (Prerequisites) </li></ul><ul><ul><li>Establish Known Irreversible Cause of Coma </li></ul></ul><ul><ul><li>Exclusion of Potentially Reversible Conditions </li></ul></ul><ul><ul><ul><li>Drug Intoxication or Poisoning </li></ul></ul></ul><ul><ul><ul><li>Electrolyte or Acid-Base Imbalance </li></ul></ul></ul><ul><ul><ul><li>Endocrine Disturbances </li></ul></ul></ul><ul><ul><li>Achieve Body temperature > 36° C </li></ul></ul><ul><ul><li>Achieve Normal Systolic BP ( > 100 mm Hg) </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  21. 21. Brain Death: Diagnosis <ul><li>04 Steps to diagnosis </li></ul><ul><li>(2) Clinical Evaluation (Neuro assessment) </li></ul><ul><ul><li>Establish Coma </li></ul></ul><ul><ul><li>Establish Absence of Brain Stem Reflexes </li></ul></ul><ul><ul><li>Establish Apnoea </li></ul></ul><ul><ul><ul><li>Absence of Respiration drive </li></ul></ul></ul><ul><li>(3) Ancillary Tests </li></ul><ul><li>(4) Documentation </li></ul><ul><ul><li>Time of death is the time the arterial PaCO2 reached the target value OR </li></ul></ul><ul><ul><li>When ancillary test officially interpreted </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  22. 22. Brain Death Neurologic Examination <ul><li>COMA </li></ul><ul><li>Establish No response to noxious stimulus </li></ul><ul><ul><li>Nail Bed pressure </li></ul></ul><ul><ul><li>Sternal Rub </li></ul></ul><ul><ul><li>Supra Orbital Ridge Pressure </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  23. 23. Brain Death Neurologic Examination <ul><li>Absent Brain Stem Reflexes </li></ul><ul><li>Pupillary Reflex (absent) </li></ul><ul><li>Eye Movements </li></ul><ul><ul><li>Occulo-Cephalic ( Dolls Eye Movements) </li></ul></ul><ul><ul><li>Occulo-Vestibular (Cold Caloric test) </li></ul></ul><ul><li>Facial Sensation and Motor Response </li></ul><ul><li>Pharyngeal (Gag) Reflex absent </li></ul><ul><li>Tracheal (Cough) Reflex Absent </li></ul>25 September 2011 Dr (Brig) YD Singh
  24. 24. Brain Death Neurologic Examination 25 September 2011 Dr (Brig) YD Singh Pupils dilated with no constriction to bright light
  25. 25. Brain Death Neurologic Examination <ul><li>Occulo Cephalic Response </li></ul><ul><li> (No Dolls Eye Movements) </li></ul>25 September 2011 Dr (Brig) YD Singh
  26. 26. Brain Death Neurologic Examination 25 September 2011 Dr (Brig) YD Singh Occulo-Vestibular Response “ Cold Caloric Testing” Normal Response in Coma No Response in Brain Stem Death
  27. 27. Brain Death Neurologic Examination 25 September 2011 Dr (Brig) YD Singh Facial Sensations & Motor Response <ul><li>Absent Corneal Reflex </li></ul><ul><li>Absent Jaw reflex </li></ul><ul><li>No response to </li></ul><ul><li>Supraorbital Or </li></ul><ul><li>Temporo-Mandibular </li></ul><ul><li>Pressure </li></ul>
  28. 28. Brain Death : Apnoea Test <ul><li>Pre-requisites </li></ul><ul><ul><li>Body Temperature > 36° C </li></ul></ul><ul><ul><li>Systolic Blood Pressure ≥ 100 mm Hg </li></ul></ul><ul><ul><li>Normal Electrolytes profile </li></ul></ul><ul><ul><li>Normal PaCO2 (35-45 mm Hg) </li></ul></ul><ul><li>Pre-Oxygenation </li></ul><ul><ul><li>100% Oxygen via Tracheal Cannula for 10 min </li></ul></ul><ul><ul><li>Achieve PaO2 = 200 mm Hg </li></ul></ul><ul><li>Monitor PaO2 with pulse oximetry </li></ul>25 September 2011 Dr (Brig) YD Singh
  29. 29. Brain Death : Apnoea Test <ul><li>Reduce Ventilation frequency to 10/min </li></ul><ul><li>Reduce PEEP to 5 Cm H2O </li></ul><ul><li>Take 1 st Blood sample for Blood Gas analysis </li></ul><ul><li>Disconnect Ventilator </li></ul><ul><li>Deliver 100% O2 by catheter through ET tube </li></ul><ul><ul><li>@ 6 L/min </li></ul></ul><ul><li>Observe for Respiratory Movement </li></ul><ul><ul><li>Atleast for 8 – 10 min </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  30. 30. Brain Death : Apnoea Test <ul><li>Discontinue Testing </li></ul><ul><ul><li>If BP drops to < 90 mm Hg </li></ul></ul><ul><ul><li>PaO2 to 85% by pulse Oxymetry for 30 Sec </li></ul></ul><ul><li>If no respiratory drive observed after 08 min </li></ul><ul><ul><li>Take next Blood sample for Blood gas studies </li></ul></ul><ul><li>If respiratory movements are absent & arterial PaCO2 is 60 mm Hg OR </li></ul><ul><ul><li>20 mm Hg over a baseline normal PaCO2 </li></ul></ul><ul><li>The Apnea test result is POSITIVE </li></ul><ul><ul><li>Supports the clinical diagnosis of brain death </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  31. 31. Brain Death Ancillary Confirmatory Testing <ul><li>Recommended when </li></ul><ul><ul><li>Proximate cause of coma is not known or </li></ul></ul><ul><ul><li>When confounding clinical conditions limit clinical examination </li></ul></ul><ul><li>EEG </li></ul><ul><li>Cerebral Angiography </li></ul><ul><li>PET : Glucose Metabolic Studies </li></ul><ul><li>Dynamic Nuclear Scan </li></ul><ul><li>Somato-Sensory Evoked Potential </li></ul>25 September 2011 Dr (Brig) YD Singh
  32. 32. Brain Death Confirmatory Testing 25 September 2011 Dr (Brig) YD Singh Electro-Cerebral Silence Normal EEG
  33. 33. Brain Death Confirmatory Testing 25 September 2011 Dr (Brig) YD Singh No Intra- Cranial Flow Normal Cerebral Angiography
  34. 34. PET Glucose Metabolism Studies 25 September 2011 Dr (Brig) YD Singh “ Hollow-skull sign” of brain death Cerebral metabolism globally reduced ~50% Normal Nature Rev Neurosci 2005;6:899-909
  35. 35. Dynamic Nuclear Brain Scan 25 September 2011 Dr (Brig) YD Singh “ Hollow-skull sign” of brain death NEJM 2001;344:1215-1221
  36. 36. Conditions Distinct from Brain Death <ul><li>Coma </li></ul><ul><li>Persistent Vegetative State </li></ul><ul><li>Locked in Syndrome </li></ul>25 September 2011 Dr (Brig) YD Singh
  37. 37. Coma <ul><li>It is a sleeplike state from which patient cannot be aroused </li></ul><ul><ul><li>It is sleep like because </li></ul></ul><ul><ul><ul><li>Eyes remain closed </li></ul></ul></ul><ul><ul><ul><li>Patient is NOT aroused even by painful stimuli </li></ul></ul></ul><ul><li>We can simplify Coma by saying: </li></ul><ul><ul><li>A state lacking Wakefulness and Awareness </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  38. 38. Persistent Vegetative state <ul><li>Patient out of Coma and appears awake </li></ul><ul><ul><li>Follows Normal Sleep-Wake Cycles </li></ul></ul><ul><li>No Response to Environmental Stimuli </li></ul><ul><ul><li>Not Aware of surroundings </li></ul></ul><ul><li>Preservation of Brain Stem Function </li></ul><ul><li>Cause : </li></ul><ul><ul><li>Diffuse Brain Injury </li></ul></ul>25 September 2011 Dr (Brig) YD Singh
  39. 39. Persistent Vegetative state 25 September 2011 Dr (Brig) YD Singh Aruna Ramachandra Shanbag Mumbai
  40. 40. Locked in Syndrome 25 September 2011 Dr (Brig) YD Singh Ventral Pontine Infarct <ul><li>Complete Paralysis </li></ul><ul><li>Consciousness is </li></ul><ul><li>Preserved </li></ul><ul><li>Preserved Eye </li></ul><ul><li>Movement </li></ul>
  41. 41. Brain Death Conclusions <ul><li>In the U.S., Brain death is considered death for all purposes </li></ul><ul><li>In India Brain death is defined in Organ transplantation act only </li></ul><ul><ul><li>It is Debatable if Brain Death applicable for non organ donation? </li></ul></ul><ul><li>We need to have Uniform Declaration of Death legislation like US to settle the issue </li></ul>25 September 2011 Dr (Brig) YD Singh
  42. 42. Brain Death Conclusions <ul><li>PVS Patient is not dead </li></ul><ul><ul><li>In a state of wakefulness without awareness </li></ul></ul><ul><li>Ancillary tests (EEG, PET) can help distinguish Coma, PVS & Locked-in state from Brain Death </li></ul>25 September 2011 Dr (Brig) YD Singh
  43. 43. Brain Death : Present Status <ul><li>Hippocrates said this long ago </li></ul><ul><li>(The Hippocratic Corpus) </li></ul><ul><li>“ First I will define what I conceive medicine to be. In general terms, it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their disease, realizing that in such cases medicine is powerless”. </li></ul>25 September 2011 Dr (Brig) YD Singh
  44. 44. Thanks !! 25 September 2011 Dr (Brig) YD Singh
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