Brain Death

The advent of improved intensive care facilities and more aggressive resuscitation techniques has led to an increase in numbers of patients with irreversible brain damage in which tissue oxygenation is maintained by a persistent heart beat and artificial ventilation.

A government working party has published guidelines for the diagnosis of brain death which, when fulfilled, indicate that recovery is impossible. In these patients, organs may be removed for transplantation before discontinuing ventilation.

The tests are designed to detect failure of brain stem function, but certain preconditions must first be met.

Preconditions

Depressant drugs must not contribute towards the patient's clinical state - if in doubt allow an adequate time interval to elapse to eliminate any possible persistent effect.

Hypothermia must not be a primary cause - ensure that temperature is not less than 35 °C.

Severe metabolic or endocrine disturbance must be excluded as a possible cause of the patient's condition.

The patient must be on a ventilator as a result of inadequate spontaneous respiration or respiratory arrest - if a neuromuscular blocking drug has been used, exclude a prolonged effect by observing a muscle twitch on nerve stimulation, e.g. electrical stimulation of the median nerve should cause a thumb twitch.

The cause of the patient's condition must be established and this must be compatible with irreversible brain damage, e.g. severe head injury, spontaneous intracerebral haematoma. If in doubt, delay brain death testing.

BRAIN DEATH TESTS

PUPIL RESPONSE

PUPIL RESPONSE

r No pupil reaction to light.

r No pupil reaction to light.

N.B. Ensure light intensity is adequate.

CORNEAL REFLEX

Wisp of cotton wool

Wisp of cotton wool

No orbicularis oculi contraction in response to corneal stimulation.

VESTIBULO-OCULAR REFLEX

GAG REFLEX

VESTIBULO-OCULAR REFLEX

No eye movements occur when 50 ml of iced water are slowly injected into the external meatus. (Ensure that the external meatus is not occluded with wax or blood.) In coma with preserved brain stem function, the eyes tonically deviate towards the tested ear after a delay of 20 seconds.

Maximal response is obtained with the head raised 30 from the horizontal.

GAG REFLEX

Bronchial stimulation (with a suction tube) fails to produce a 'cough' response.

Suction tube

Bronchial stimulation (with a suction tube) fails to produce a 'cough' response.

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