Brain stem death is a type of brain death defined by the absence of brain stem function and reflexes. This results in the permanent loss of consciousness, breathing ability, and other vital functions controlled by the brain stem. Diagnosing brain stem death requires demonstrating the lack of brain stem reflexes, spontaneous breathing, and movement in response to stimuli, along with fixed and dilated pupils and an isoelectric EEG over two examinations 24 hours apart.

1. BRAIN STEM
DEATH

2. BRAIN DEATH
Its of 3 types
CORTICAL OR CEREBRAL DEATH
BRAINSTEM DEATH
WHOLE BRAIN DEATH

3. BRAIN STEM DEATH
• Brain stem death is a clinical
syndrome defined by the absence of reflexes
with pathways through the brain stem - the
“stalk” of the brain, which connects the
spinal cord to the mid-brain, cerebellum and
cerebral hemispheres.

4. • Loss of vital centres that control respiration
and of ARAS that retain consciousness
------> victim is irreversibly comatose and
incapable of spontaneous breathing
(apnoeic).
• i.e. brainstem death is when a person no
longer has any activity in their brainstem, and
has permanently lost the potential for
consciousness and the capacity to breathe.

5. • Can be produced by
–Raised intra cranial pressure
–Cerebral edema
–Intracranial hemorrhage etc.

6. VARIOUS CRITERIA FOR
DETERMINING
BRAIN DEATH

7. PHILADELPHIA PROTOCOL (1969)
MINNESOTA CRITERIA (1971)
HARVARD CRITERIA

8. HARVARD CRITERIA

9. 1. Unreceptivity and unresponsivity
• Total unawareness to external stimuli and
inner need
• Complete unresponsiveness to even most
intense painful stimuli

10. 2. No movements
• No spontaneous muscular movements in
response to stimuli such as:
– Pain
– Touch
– Sound
– Light
- for atleast 1 hour

11. 3. Apnoea
• Absence of complete breathing for one hour
• If patient is on ventilator, total absence of
spontaneous breathing is established by
turning off the respirator for 3 minutes and
observing whether there is any effort from
the subject to breathe spontaneously

12. 4. Absence of elicitable reflexes
• Pupils are fixed and dilated, does not respond
to light
• Ocular movement and blinking absent
• No evidence of postural activity
• Corneal and pharyngeal reflexes absent
• Stretch tendon reflexes also lost

13. 5. Isoelectric EEG
• Confirmatory test

16. • All the tests should be repeated after 24
hours with no change in results.

17. • Two schools of diagnosing death :
1. French and English school – similar to
Harvard
2. Austro-German school – includes Harvard
criteria and bilateral serial angiography of
internal carotid and vertebral artery criteria.
- a negative angiogram for more than 15
minutes proves death

18. DIAGNOSIS OF BRAINSTEM
DEATH
EXCLUSIONS
1. Patient may be under effect of drugs,
eg:- therapeutic overdoses.
2. Core temperature of body is below35oC,
hypothermia.
3. Severe metabolic or endocrine disturbances that
may lead to severe irreversible coma,
eg:- diabetes.

19. PRECONDITIONS OF DIAGNOSIS
• Patient must be deeply comatose
• Patient must be maintained on a ventilator
• Cause of the coma must be known

20. PERSONNEL WHO SHOULD PERFORM
THE TESTS
• Must be performed by 2 medical practitioners
• Doctors involved should be experts
• Transplant surgeons under no circumstances can perform
the test
• At least one of the doctors should be of consultant status,
junior doctors are not allowed
• Each doctor should perform the test twice

21. TESTS TO BE PERFORMED
• Before the tests, it is ensured that core
temperature of body is above 35oC
• Cranial nerves that pass through brain stem
are tested.

22. 1. Pupils are fixed in diameter and do not respond to
changes in intensity of light
2. No corneal reflex
3. Vestibulo-ocular reflexes are absent (no ocular
movement after instillation of cold water into
outer ears)
4. No motor responses within the cranial nerve
distribution can be elicited by painful stimulation
5. No gag reflex
6. No respiratory movements occur when patient is
disconnected from ventilator (long enough to
ensure CO2 concentration rises above the
threshold to stimulate respiration)

23. • When two doctors have performed these
tests twice with negative results, the patient
is pronounced dead and a death certificate
can be issued.

24. Thank you…