Brain Death

MOTOR RESPONSE No motor response in the face or in the muscles supplied by cranial nerves in response to a painful stimulus, e.g. supraorbital pain.

MOTOR RESPONSE No motor response in the face or in the muscles supplied by cranial nerves in response to a painful stimulus, e.g. supraorbital pain.

N.B. Limb responses are of no value in testing brain stem integrity. Movements can occur in response to limb or trunk stimulation (especially in the legs), and tendon reflexes may persist in a patient with brain stem death but intact cord function. Conversely, limb movements and reflexes may be absent in a patient with an intact brain stem and spinal cord damage.

RESPIRATORY MOVEMENTS

No respiratory movements are observed when the patient is disconnected from the ventilator. During this test, anoxia is prevented by passing 6 litres 02 per minute down the endotracheal tube. This should maintain adequate P02 levels for up to 10 minutes. N.B. Ensure that apnoea is not a result of a low PC02■ This should be greater than 6.65 kPa (50 mmHg).

Clinician's status

The British recommendations state that these tests should be carried out by two doctors, both with expertise in the field; one of consultant status, the other of consultant or senior specialist registrar status. The doctors may carry out the tests individually or together.

Test repetition and timing

The test should be repeated but the interval should be left to the discretion of the clinician. The initial test may be performed within a few hours of the causal event, but in most instances is delayed for 12-24 hours, or longer if there is any doubt about the preconditions.

Timing of death

Certification of death occurs when brain death is established, i.e. at the time of the second test. Old concepts of death occurring at the time the heart ceases to beat are no longer applicable.

Supplementary investigations

Electroencephalography (EEG) is of no value in diagnosing brain death. Some patients with the potential to recover show a 'flat' trace; in others with irreversible brain stem damage, electrical activity can occasionally be recorded from the scalp electrodes.

Similarly, angiography or cerebral blood flow measurement are of no additional value to the clinical tests described above, provided the preconditions are fulfilled.

SECTION IV

LOCALISED NEUROLOGICAL DISEASE

AND ITS MANAGEMENT A. INTRACRANIAL

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