Lecture for Undergraduate Nursing Students

1. Brain Death
Prepared By
Dr. Zuhair Rushdi Mustafa
Lecturer at University of Duhok/ College
of Nursing

2. Parts of the brain
Cerebral hemispheres:
 Responsible for:
 Conscious part of the brain
 Controls thought and memory
 Feels sensations
 Directs conscious movements

3. Parts of the brain
Thalamus Responsible for:
 Relay station for sensory information to go to the brain
Hypothalamus Responsible for:
 Temperature control, controls hormone systems, food
intake, emotions

4. Parts of the brain
Cerebellum: Responsible for:
 Balance
 Coordination

5. Parts of the brain
Brain stem: Midbrain + Pons + Medulla
 Attention, arousal & consciousness
 Cranial nerve reflexes
 Control of breathing
 Control of blood pressure, heart function
Brainstem function is vital for preservation of life!

6. Brain Death is the irreversible loss of
capacity for consciousness combined with
the irreversible loss of all brainstem
functions including the capacity to breathe.
brainstem is considered equivalent to brain
death, because brainstem is essential to
maintain life.
Heartbeat may continue!
Brain Death Definition

7. Heart, Lung, Liver, Kidneys etc.
are vital organs
but
can be supported by technology
or replaced by transplantation.
except
The Brain
Why
only Brain death is death ?
7

8. Who may become
brain dead ?
Only patients with acute cerebral
lesion under mechanical
ventilation in ICU Such as Brain
injury – Cerebral Hemorrhage
Ischemic Stroke – Brain Tumour
Anoxia – Cerebral Infection etc.

9. Determination of Brain Death
 An individual who has sustained either:
1) irreversible cessation of circulatory and
respiratory function or
2) irreversible cessation of all function of the
entire brain, including brain stem, is dead.

10. Criteria for CNS Determination of
Death (Brain Death)
 Irreversible coma
 Absence of cortical function
 Absence of brainstem function
 Apnea
 Ancillary tests

11. Basic exam for brain Death
1 - Pain
 Cerebral motor response to pain
Supraorbital ridge, the nail beds, trapezius
Motor responses may occur spontaneously
during apnea testing (spinal reflexes).

12. 2 - Pupils
 Round, oval, or irregularly shaped
 Midsize (4-6 mm), but may be totally dilated
 Absent pupillary light reflex
 the light reflex remains intact only in the absence of brain
death. Pupils are mid-position and do not react to light in
brain death.

13. 3.Eye movement
 Oculocephalic reflex = doll’s eyes
 Oculovestibular reflex = cold caloric test

14. Oculocephalic reflex
 Rapidly turn the head 90° on both sides
In Normal response there will be 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
 Like old fashioned type of dolls

15. Eye Movements
Occulo-Cephalic Response
“Doll’s Eyes Maneuver”

16.  Oculovestibular testing (cold water
calorics). Irrigate one tympanic membrane
with iced water.
 Head of bed 30 degrees, 20 mL ice water
irrigation of each patent ear canal with 5 minutes
observation and 5 minutes wait between testing
of each ear.
 If there is a ruptured Tympanic Membrane, you must
skip this ear

17. Cold calorics interpretation Results
 Not comatose
 Nystagmus; both eyes slow toward cold, fast to
midline.

 Coma with intact brainstem
 Both eyes tonically deviate toward cold water
 No eye movement
 Brainstem injury / death
 Movement only of eye on side of stimulus
 Suggests brainstem structural lesion

19. 4. Facial sensory & motor responses
 Corneal reflexes are absent in brain death
Corneal reflexes - tested by using a cotton-
tipped swab. Eyes does not blink when touched
(corneal reflex) Indicate Brain Death.
Grimacing in response to pain can be tested by
applying deep pressure to the nail beds,
supraorbital ridge, or swab in nose. No response
indicate Brain Death

20. 5. Pharyngeal and tracheal reflexes
 Both gag and cough reflexes are absent in
patients with brain death
Gag reflex can be evaluated by stimulating
the posterior pharynx with a tongue
Depressor, but the results can be difficult to
evaluate in orally intubated patients.
Cough reflex can be tested by using
Endotracheal tube ETT suctioning, past end
of ETT

21. Ancillary & Confirmatory Testing
 Electroencephalogram EEG, MRI, cerebral
angiography, and nuclear scans and
perfusion scan have all been used to
confirm brain death.
 Used when standard testing impossible or
inconclusive (i.e. Pharyngeal and tracheal
reflexes).
 EEG shows no brain activity (flat waves) is
diagnostic of brain death

22. Cerebral perfusion scan

23. Cerebral Angiography
Presence of dye = blood flow. Absence of dye = brain death

24. How to make it clear
 Say “dead”, not “brain dead”
 Say “artificial or mechanical ventilation”,
not “life support”
 Tim e of death = neurologic determination
NOT when ventilator removed
NOT when heart beat ceases
 Do not say “kept alive” for organ donation
 Do not talk to the pt as if he’s still alive