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BrainDeath

AnatomyandPhysiologyJoelS.Cohen,M.D.AssociateProfessorofClinicalNeurologyAlbertEinsteinCollegeofMedicineHistoricalPerspective

Priortotheadventofmechanicalrespiration,deathwasdefinedasthecessationofcirculationandbreathingHistoricalPerspective1959Comade’passe’MollaretandGoulon1968IrreversibleComa/BrainDeathHarvardMedicalSchoolAdHocCommittee

1981UniformDeterminationofDeathAct-President’sCommissionfortheStudyofEthicalProblemsinMedicine1994AmericanAcademyofNeurologyGuidelinesforthedeterminationofBrainDeath2005NYSGuidelinesforDeterminingBrainDeathNormalBrainAnatomyNormalBrainAnatomyCerebralCortexBrainStemReticularActivatingSystemCerebralCortexCognitionVoluntaryMovementSensationBrainStemBrainStemPonsCranialNervesIV,V,VIconjugateeyemovementcornealreflex

ReticularActivatingSystemReceivesmultiplesensoryinputsMediateswakefulnessCausesofBrainDeathNormalCerebralHemorrhageCausesofBrainDeathNormalSubarachnoidHemorrhageCausesofBrainDeathNormalTraumaCausesofBrainDeathNormalMeningitisMechanismofCerebralDeathNeuronalInjury

DecreasedIntracranialBloodFlow

NeuronalSwellingIncreasedIntracranialPressureICP>MAPisincompatiblewithlifePersistentVegetativeStateNormalSleep-WakeCyclesNoResponsetoEnvironmentalStimuliDiffuseBrainInjurywithPreservationofBrainStemFunctionLocked-inSyndromeVentralPontineInfarctCompleteParalysisPreservedConsciousnessPreservedEyeMovementBrainDeathNeurologicalExaminationClinicalPrerequisites:KnownIrreversibleCauseExclusionofPotentiallyReversibleConditionsDrugIntoxicationorPoisoningElectrolyteorAcid-BaseImbalanceEndocrineDisturbancesCoreBodytemperature>32°CBrainDeathNeurologicalExaminationComaAbsentBrainStemReflexesApneaAbsenceofBrainStemReflexesPupillaryReflexEyeMovementsFacialSensationandMotorResponsePharyngeal(Gag)ReflexTracheal(Cough)ReflexPupillaryReflexPupilsdilatedwithnoconstrictiontobrightlightEyeMovementsOcculo-CephalicResponse“Doll’sEyesManeuver”FacialSensationandMotorResponseCornealReflexJawReflexGrimacetoSupraorbitalorTemporo-MandibularPressureApneaTestingPrerequisitesCoreBodyTemperature>32°CSystolicBloodPressure≥90mmHgNormalElectrolytesNormalPCO2

ApneaTesting1.Pre-Oxygenation100%OxygenviaTrachealCannulaPO2=200mmHg2.MonitorPCO2andPO2withpulseoximetry3.DisconnectVentilator4.ObserveforRespiratoryMovementuntilPCO2=60mmHg5.DiscontinueTestingifBP<90,PO2saturationdecreases,orcardiacdysrhythmiaobserved ConfoundingClinicalConditionsFacialTraumaPupillaryAbnormalitiesCNSSedativesorNeuromuscularBlockersHepaticFailurePulmonaryDiseaseObservationsCompatiblewithBrainDeathSweating,BlushingDeepTendonReflexesSpontaneousSpinalReflexes-TripleFlexionBabinskiSignConfirmatoryTestingRecommendedwhentheproximatecauseofcomaisnotknownorwhenconfoundingclinicalconditionslimittheclinicalexaminationConfirmatoryTestingEEGNormalElectrocerebralSilenceConfirmatoryTestingCerebralAngiographyNormalNoIntracranialFlowConfirmatoryTestingTechnetium-99IsotopeBrainScan

ConfirmatoryTestingMR-AngiographyConfirmatoryTestingTranscranialUltrasonographyConfirmatoryTestingSomatosensoryEvokedPot

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