How to Diagnose brain death To download send me an email to sherif_badrawy@yahoo.com

2. What is the difference between
an anatomic coma and a
metabolic coma? Examples.
1a
Dr. Sherif
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3. -An anatomic coma involves 【mechanical
destruction】 of the brainstem or cerebral
cortex (i.e.: hemorrhagic stroke, car
accident)
-A metabolic coma is 【global disruption
of metabolic processes】 (i.e.: electrolyte
imbalance)
1b

4. What are the requirements
under the state *regulations for
determining brain death? Name
5
2a

5. - 【a QUALIFIED PHYSICIAN】
-Physician acts in good faith (【not part of
transplant team】 imposing a conflict of
interest)
-【Number of physicians (at least 2)】
-Religious exemption
-Medical standards
2b

6. Although there is no gold
standard about what constitutes
brain death, how is it generally
determined.
3a

7. Bedside & clinical diagnosis
3b

8. Clinical diagnosis of brain death
can be made without
confirmatory testing if you are
able to:
4a

9. -Establish the 【etiology】
-【Eliminate reversible causes】 of
coma
-Complete fully the 【neurological
exam & apnea testing】
4b

10. Diagnosis of brain death requires
demonstration of the absence of
both____and___activity
5a

11. Cortical and Brain stem (more
subjective as opposed to
objective)
5b

12. What is the hospital policy for
brain death? *
6a

13. -Requires 2 independent exams
-A neurologist or neurosurgeon
must perform one of the exams
-Document exam in medical record
-Determination is made in ICU
6b

14. Which irreversible states can
produce brain death?
7a

15. -Head Trauma
-Intracranial hemorrhage
-Brain tumor
-Cerebral edema
-Hypoxia
-Cerebrovascular injury
7b

16. What are the contraindications
addressed/corrected prior to
diagnosing brain death?
8a

17. -Hypothermia
-Hypotension
-Drug overdose/toxicity, poisoning, or
neuromuscular blocking agents
-Severe electrolyte, endocrine, acid-base imbalance
-Locked-in syndrome
-Postical state (following severe tonic -clonic
seizure)
8b

18. What medical criteria is required
prior to a brain dead diagnosis?
3
9a

19. -Absence of【cerebral function】
(all lobes must be assessed)
-Absence of 【brain stem
function】 (CN assessment)
-【Apnea】
9b

20. absence of cerebral function?
Characteristics? *
10a

21. -Total unresponsiveness to visual,
auditory, and central pain
-No spontaneous movement (swallowing,
yawning)
-No vocal response
-No cough
-Lazarus sign
10b

22. What is a Lazarus sign?
11a

23. 【Spinal cord
reflexes】compatible with brain
death diagnosis; mainly seen in
teenagers and children
11b

24. What are the steps taken in
diagnosis a brain stem function?
12a

25. -Fixed, nonreactive pupils
-Absence of spontaneous eye movement
-Absence of oculovestibular reflex &
oculocephalic response (CN 3, 6, 8)
-Absent gag reflex (CN 9 & 10)
-Absent cough reflex
-Absent corneal reflex (5 & 7)
-Absence of respiratory function
12b

26. How is the oculovestibular reflex
performed? Interpretation of
results?
13a

27. ice h20 placed in eardrum. If there
is a brainstem injury, the eyes would
stay midline and if the brainstem is
intact, the eyes will go the opposite
way
【cOld = Opposite, Warm = With】
13b

28. How is the oculocephalic
response done?
14a

29. Open eyelids and turn head side
to side
14b

30. What corresponds to an absence
of respiratory function?
Characteristics? *
15a

31. No evidence of spontaneous
breathing
15b

32. Apnea Test Prerequisites
16a

33. Core Body Temp ≥ 36.5°C or 97°F
SBP ≥90 mmHg
DI under control (positive fluid balance for past
6 hours)
pCO2 must be normal (arterial ≥40 mmHg)
Pre-oxygenation up to arterial pO2 ≥ 200 mmHg
16b

34. How is the absence of respiratory
function determined? STEPS.
17a

35. -Apnea test
1. Preoxygenate (100%)
2. Baseline ABG (to see what the CO2 is)
3. Disconnect ventilator (but do not take oxygen away)
4. Administer oxygen
5. Observe respirations
6. Draw ABG (8-10 min)
7. A pCO2 of ≥ 60 mmHg or an increase of ≥ 20 mmHg over
a normal baseline with no respiratory effort supports a
positive apnea test and is consistent with brain death.
17b

36. Why would the apnea test be
aborted?
18a

37. -Patient breaths
-HD instability
-Hypoxia
-Arrhythmia
18b

38. What would be the best
confirmatory test for brain
death? What would it
demonstrate?
19a

39. Cerebral Blood flow- nuclear
scan; No uptake of radionuclide
in brain parenchyma "hollow
skull phenomenon"- NO FLOW
19b

40. Why is an EEG not typically done
as a confirmatory test?
20a

41. Because it can show artifacts
20b

42. Describe the process related to
organ donation. *
21a

43. -Ensure the option of anatomical donation is
presented to the family on all deaths
-Hospital must notify OPO of individuals whose
death is imminent or who have died in the
hospital
-OPO determines medical suitability
-Hospital and OPO will work collaboratively
21b

44. How are the organs of donors
managed?
22a

45. -Optimize oxygenation
-Prevent pulmonary complications
-Maintain body temps
-Hemodynamic stability (BP)
-Fluid & electrolyte balance
22b

46. 1 donor has the potential to
save____lives
23a

47. 8
23b

48. What ancillary test has not been
validated for use as a
confirmatory test yet?
24a

49. Computed Tomography
Angiogram (CTA/MRI)
24b

50. When can one perform an
ancillary test without the 3
standard components of DNC? 3
Reasons
25a

51. -Apnea test is aborted
-Drug toxicity
-Cant correct metabolic
dysfunctions
25b

52. Can the death by neurological
criteria be determined if there is
no cause for irreversible injury?
26a

53. No
26b

54. What PCO2 levels would support
a diagnosis of DNC?
27a

55. If the pCO2 rises to greater than 60mmHg or
20mmHg higher than the pretest pCO2 and the
patient has no respiratory effort, the test
supports the diagnosis of death by neurological
criteria.
27b

56. The transcranial doppler test
(TCD) looks for?
28a

57. The abnormalities include a lack
of diastolic or reverberation flow
and documentation of small
systolic peaks in early systole.
28b