References

1. Conference of Medical Royal Colleges and the Faculties in the United Kingdom. Diagnosis of Brain Stem Death. BMJ 1976;2:1187-8.

2. Wijdicks EFM. Brain Death Worldwide. Neurol 2002;58:20-5.

3. Shewmon DA. Chronic "Brain Death", Meta-analysis and Conceptual Consequences. Neurol 1998;1538-45.

4. Cranford RE. Discontinuation of ventilation after brain stem death, policy should be balanced with concern for the family. BMJ 1999;318:1754-5.

5. Jennett B. Discontinuation of ventilation after brain stem death, brain stem death defines death in law. BMJ 1999;318:1755.

6. O'Brien MD. Criteria for diagnosing brain stem death. BMJ 1990;301: 108-9.

7. Pallis C. ABC of Brain Stem Death. London: British Medical Association, 1983.

8. Pallis C. Brain stem death. In: Vinken PJ, Bruyn GW, Klawans HL, eds. Handbook of clinical neurology. New York: Elsevier, 1990, pp 441-96.

Assessment form

Date of birth Hospital number

Assessor A Assessor B Assessor A Assessor B

Name Status

If a patient in deep coma, requiring mechanical ventilation, is thought to be dead because of irreversible brain damage of known cause, an assessment of brain stem function should be made according to the following guidelines. These follow the Department of Health recommendations in "Cadaveric organs for transplantation - a code of practice, including the diagnosis of brain death", 1983 (London: HMSO).

Two assessments should be made by two doctors once the preconditions have been met. Diagnosis should not normally be considered until at least six hours after the onset of coma or, if anoxia or cardiac arrest was the cause of the coma, particularly in children, until 24 hours after the circulation has been restored, and then only if the preconditions have been satisfied.

(1) Two medical practitioners, who have expertise in this field, should assure themselves that the preconditions have been met before the examination.

(2) It is often convenient for the examination to be performed by one assessor and witnessed by the other.

(3) The respirator disconnection test is usually performed by an anaesthetist and witnessed by one of the assessors.

What is the cause of the irremediable brain damage? Why is it irremediable?

Start of coma: Time Date

Preconditions (All answers must be "No") Time

Date

1 Could primary hypothermia, drugs, or metabolic/ endocrine abnormalities be contributing significantly to the apnoeic coma? (Where appropriate, check plasma and urine for drugs, and plasma pH, glucose, sodium, and calcium.)

2 Have any neuromuscular blocking drugs been administered during the preceding 12 hours?

3 Is the rectal temperature below 35°C? (If so, warm the patient and reassess.)

Examination

Do not proceed until the preconditions have been met. The answer to all questions must be "No".

Examination

Do not proceed until the preconditions have been met. The answer to all questions must be "No".

A

B

A

B

Time Date

1 When the head is gently but fully rotated to either side is there conjugate deviation of the eyes in the opposite direction (Doll's head eye movement)?

2 Do the pupils react to light?

3 Is there any response to corneal stimulation on either side?

4 Do the eyes deviate when either ear is irrigated with 50 ml of ice cold water for 30 seconds? (First confirm tympanic membranes visible and intact.)

5 Is there a gag reflex?

6 Is there a cough reflex following bronchial stimulation by a suction catheter?

7 Are there any motor responses within the cranial nerve distribution following adequate stimulation of any somatic area? (Supraorbital and nail bed pressure.)

8 Tests for spontaneous ventilation

Are there any spontaneous respiratory movements?

Pre-oxygenate the patient for 10 minutes with 100% oxygen. Record blood gases (Paco2 before disconnection must exceed 5-3 kPa. If not, slow ventilation until Paco2 rises to this level). Ventilation with 95% O2 and 5% CO2 is an alternative.

CO2

O2

CO2

O2

Disconnect the patient from the ventilator and give oxygen at 6 litres per minute via a suction catheter in the trachea. Wait approximately 10 minutes, then measure blood gases (PacO2 must exceed 6-65 kPa at the end of the disconnection period).

Is there any spontaneous respiratory movement?

Assessors' signatures

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