Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Brain death presentation

12,839 views

Published on

Brain death implies the permanent absence of cerebral and brainstem functions.
criteria for dx
clinically
confirmatory dx
decision

Published in: Health & Medicine
  • Login to see the comments

Brain death presentation

  1. 1. Brain death 24 May 2016 brain death
  2. 2. Brain Death Out line  What is brain death?  Causes of Brain Death  Clinical evaluation of brain death  Brain Death Diagnosis 24 May 2016 brain death
  3. 3. Normal Brain Anatomy 24 May 2016 brain death Cerebral Cortex Brain Stem Reticular Activating System Receives multiple sensory inputs & Mediates Consciousness (wakefulness)
  4. 4. Cerebral Cortex: Function 24 May 2016 brain death  Cognition  Voluntary Movement  Sensation
  5. 5. Brain Stem : Functions 24 May 2016 brain death Medulla Cranial Nerve IX, X  Pharyngeal (Gag) Reflex  Tracheal (Cough) Reflex Respiration
  6. 6. Death : Definition  Thanatology  Branch of science dealing with study of death  Death is the complete and irreversible stoppage of  Circulation  Respiration  Brain function (Tripod of life)  As long as oxygenated blood reaches brain stem, Life exists ….  Mechanical Ventilator use in ICU  Brought concept of “Brain Death” 24 May 2016 brain death
  7. 7. Brain Death  Ireversible destruction of the brain,with the resulting total absence of all cortical and brainstem functions,although spinal cord refleves may remain 24 May 2016 brain death
  8. 8. Conditions Distinct from Brain Death  Coma  Persistent Vegetative State  Locked in Syndrome 24 May 2016 brain death
  9. 9.  3 clinical findings necessary to confirm irreversible cessation of all functions of the entire brain, including brain stem Coma (with a known cause) Absence of brainstem reflexes Apnoea 24 May 2016 brain death
  10. 10. Causes: Brain Death 24 May 2016 brain death Normal Cerebral Anoxia
  11. 11. Causes: Brain Death 24 May 2016 brain death Normal Cerebral Haemorrhage
  12. 12. Causes: Brain Death 24 May 2016 brain death Normal Cerebral Trauma
  13. 13. Brain Death : Mechanism 24 May 2016 brain death Neuronal Injury Decreased Intracranial Blood Flow Neuronal Swelling Increased Intracranial Pressure ICP > MAP is incompatible with life
  14. 14. 4 Steps in Determining Brain Death  The Clinical Evaluation  The Neurologic Assessment  Ancillary Test  Documentation
  15. 15. Clinical evaluation of brain death Irreversible coma  Known etiology and or reversible causes ruled out  Must have an absence of  Hypothermia (>32.50C)  Neuromuscular blockade and Shock  Significant levels of sedatives  Severe metabolic distrubance and Endocrine abnormalities  Poisoning 24 May 2016 brain death
  16. 16. Absence of cortical functions  No spontaneous movement, eye opening, or movement or response after auditory, verbal, or visual commands  Cerebral motor response to pain  Supraorbital ridge, the nail beds, trapezius  Motor responses may occur spontaneously during apnea testing (spinal reflexes)  Spinal arcs are intact! 24 May 2016 brain death
  17. 17. Absence of brain stem function-1)Pupillary reflex 2)Corneal reflex 3)Gag reflex 4)Cough reflex 5)Oculocephalic reflex (doll’s eye reflex) 6)Oculovestibular reflex (caloric reflex) 7)No integrated motor response to pain 8)Apnea testing 24 May 2016 brain death
  18. 18. Pupillary reflex-  pupils may be midposition or dilated (4 to 9 mm)  Absent pupillary light reflex  IV atropine does not markedly affect response  Paralytics do not affect pupillary size  Topical administration of drugs and eye trauma may influence pupillary size and reactivity 24 May 2016 brain death
  19. 19. Corneal reflex-  Corneal reflexes are absent in brain death  Corneal reflexes - tested by using a cotton-tipped swab . There is no blink response to direct corneal stimulation. 24 May 2016 brain death
  20. 20. Oculocephalic reflex  Rapidly turn the head 90° on both sides  Normal response = deviation of the eyes to the opposite side of head turning  Brain death = oculocephalic reflexes are absent (no Doll’s eyes) = no eye movement in response to head movement 24 May 2016 brain death
  21. 21. 24 May 2016 brain death
  22. 22. Vestibularocular reflex  No eye movements within 3 mints after irrigating each tympanic membrane (if intact) sequentially with 50 ml ice water for 30 to 45 seconds while the head of the supine patient is elevated 30 degrees Retained vestibulocular reflex 24 May 2016 brain death
  23. 23. Cold calorics interpretation  Not comatose  Nystagmus; both eyes slow toward cold, fast to midline  Coma with intact brainstem  Both eyes tonically deviate away cold water  No eye movement  Brainstem injury / death  Movement only of eye on side of stimulus  Internuclear ophthalmoplegia  Suggests brainstem structural lesion 24 May 2016 brain death
  24. 24. Brain Death : Apnoea Test  Pre-requisites  Body Temperature > 36° C  Systolic Blood Pressure ≥ 100 mm Hg  Normal Electrolytes profile  Normal PaCO2 (35-45 mm Hg)  Pre-Oxygenation  100% Oxygen via Tracheal Cannula for 10 min  Achieve PaO2 = 200 mm Hg  Monitor PaO2 with pulse oximetry 24 May 2016 brain death
  25. 25. Brain Death : Apnoea Test  Reduce Ventilation frequency to 10/min  Reduce PEEP to 5 Cm H2O  Take 1st Blood sample for Blood Gas analysis  Disconnect Ventilator  Deliver 100% O2 by catheter through ET tube  @ 6 L/min  Observe for Respiratory Movement  Atleast for 8 – 10 min 24 May 2016 brain death
  26. 26. Interpreting the test  The apnea test is POSITIVE (i.e., supports the diagnosis of brain death) if:  There are no respiratory efforts during the test AND  Repeat ABG shows PCO2 > 60 mm Hg. 24 May 2016 brain death
  27. 27. Interpreting the test  The apnea test is INDETERMINATE if:  after 10 minutes, the patient demonstrates no respiratory effort, but the PCO2 is < 60 mm Hg.  The apnea test is NEGATIVE (i.e., does NOT support the diagnosis of brain death) if:  the patient demonstrates any respiratory effort at any time during the test.  Cease the test and reconnect the ventilator immediately upon observing respiratory effort. 24 May 2016 brain death
  28. 28. The Apnea Test  If the patient becomes unstable at any point during the Apnea Test (i.e. SBP drops less than 90, significant desaturation on pulse-oximetry, observance of cardiac arrhythmias, etc.), the test should be aborted.  The Apnea Test should not “induce a code!” 24 May 2016 brain death
  29. 29. Movements originating from the spinal cord or peripheral nerve which occur in brain death  Spontaneous 'spinal' reflexes in the limbs  Respiratory-like movements  Sweating, blushing, tachycardia  Normal BP  Normal osmolar control mechanism  Deep tendon reflexes, Babinski's reflex  Facial myokymias 24 May 2016 brain death
  30. 30. Brain Death Ancillary Confirmatory Testing  Recommended when  Proximate cause of coma is not known or  When confounding clinical conditions limit clinical examination  EEG  Cerebral Angiography  PET : Glucose Metabolic Studies  Dynamic Nuclear Scan  Somato-Sensory Evoked Potential 24 May 2016 brain death
  31. 31. Brain Death Confirmatory Testing 24 May 2016 brain death Electro-Cerebral SilenceNormal EEG
  32. 32. Brain Death Confirmatory Testing 24 May 2016 brain death No Intra- Cranial FlowNormal Cerebral Angiography
  33. 33. PET Glucose Metabolism Studies 24 May 2016 brain death “Hollow-skull sign” of brain death Cerebral metabolism globally reduced ~50% Normal Nature Rev Neurosci 2005;6:899-909
  34. 34. Dynamic Nuclear Brain Scan 24 May 2016 brain death “Hollow-skull sign” of brain death NEJM 2001;344:1215-1221

×