1. Brain Death Nancy G. Hoover, MD

2. Background President’s Commission report - 1981  First formalized criteria for determination of brain death  Criteria for adults National Task Force – 1987  Assembled to recommend guidelines for the determination of cerebral death in children

3. 1987 Task force Recommendations Presence of coma and apnea Absent brainstem function Absent oculocephalic and oculovestibular reflexes No cough, gag or corneal reflexes Spinal arcs could be present Time delay between exams recommended based on patient age  7 d – 2 mo = 48 hr and 2 EEG  2 mo – 1 yr = 24 hr and 2 EEG  >1 yr = 12 hr, no EEG

4. Criteria for CNS Determination of Death (Brain Death) Irreversible coma Absence of cortical function Absence of brainstem function Apnea 2 examinations with interval according to patient’s age Ancillary tests

5. Irreversible Coma Known etiology and or reversible causes ruled out Must have an absence of  Hypothermia (>32.5 0 C)  Neuromuscular blockade  Shock or significant hemodynamic instability  Significant levels of sedatives  Severe metabolic distrubance

6. Basic exam 1 - Pain Cerebral motor response to pain  Supraorbital ridge, the nail beds, trapezius  Motor responses may occur spontaneously during apnea testing (spinal reflexes)  Spinal reflex responses occur more often in young  If pt had NMB, then test w/ train-of-four Spinal arcs are intact!

7. Basic exam 2 - Pupils Round, oval, or irregularly shaped Midsize (4-6 mm), but may be totally dilated Absent pupillary light reflex  Although drugs can influence pupillary size, the light reflex remains intact only in the absence of brain death  IV atropine does not markedly affect response  Paralytics do not affect pupillary size  Topical administration of drugs and eye trauma may influence pupillary size and reactivity  Pre-existing ocular anatomic abnormalities may also confound pupillary assessment in brain death

9. Basic exam 3 Eye movement Oculocephalic reflex = doll’s eyes Oculovestibular reflex = cold caloric test

10. Oculocephalic reflex Rapidly turn the head 90° on both sides  Normal response = deviation of the eyes to the opposite side of head turning  Brain death = oculocephalic reflexes are absent (no Doll’s eyes) = no eye movement in response to head movement Not Barbie, but old fashioned type dolls

11. Cold calorics Elevate the HOB 30° Irrigate one tympanic membrane with iced water  Observe pt for 1 minute after each ear irrigation, with a 5 minute wait between testing of each ear  Facial trauma involving the auditory canal and petrous bone can also inhibit these reflexes

12. Cold calorics interpretation Not comatose  Nystagmus; both eyes slow toward cold, fast to midline Coma with intact brainstem  Both eyes tonically deviate toward cold water No eye movement  Brainstem injury / death Movement only of eye on side of stimulus  Internuclear ophthalmoplegia  Suggests brainstem structural lesion

14. Basic exam 4 Facial sensory & motor responses Corneal reflexes are absent in brain death  Corneal reflexes - tested by using a cotton- tipped swab  Grimacing in response to pain can be tested by applying deep pressure to the nail beds, supraorbital ridge, TMJ, or swab in nose  Severe facial trauma can inhibit interpretation of facial brain stem reflexes

15. Basic exam 5 Pharyngeal and tracheal reflexes Both gag and cough reflexes are absent in patients with brain death  Gag reflex can be evaluated by stimulating the posterior pharynx with a tongue blade, but the results can be difficult to evaluate in orally intubated patients  Cough reflex can be tested by using ETT suctioning, past end of ETT

16. Basic exam 6 Apnea P a CO 2 levels greater than 60 mmHg, ≥20 mmHg over baseline Technique:  Pre-oxygenate with 100% oxygen several min  Allow baseline P a CO 2 to be ~40 mmHg  Place pt on CPAP or bag-ETT  Observe for respirations for ~6-10 minutes  Get ABG to determine P a CO 2

17. Confirmatory testing 4 vessel angiography EEG  30 minutes Cerebral blood flow = perfusion scan

18. Cerebral perfusion scan

19. Kids over 1 year old Absence of all brain and brainstem function  Comatose: no purposeful response to any stimulus  Brainstem function is absent when: Pupils are mid-position and do not react to light Eyes does not blink when touched (corneal reflex) Eyes do not rotate in the socket when the head is moved from side to side (oculocephalic reflex). Eyes do not move when ice water is placed in the ear canal (oculovestibular reflex) Child does not cough or gag when a suction tube is placed deep into the breathing tube Child does not breathe when taken off the ventilator Repeat in ~6 hours

20. Children under 1 year Necessary to repeat the clinical examination after an ‘appropriate’ observation period has passed Age 7 days to 2 months Two examinations 48 hours apart and one EEG Age 2 months-1 year Two examinations 24 hours apart and one EEG or perfusion scan Confirmatory EEG unless it is determined that there is no blood flow to the brain

21. Common misconceptions Since there is a heartbeat, he is alive  Brain dead pts have permanently lost the capacity to think, be aware of self or surroundings, experience, or communicate with others He’s in a coma  Reinforce that they are dead With rehab/time he’ll get better  Irreversible, dead brain cells do not regrow

22. How to make it clear Say “dead”, not “brain dead” Say “artificial or mechanical ventilation”, not “life support” Time of death = neurologic determination  NOT when ventilator removed  NOT when heart beat ceases Do not say “kept alive” for organ donation Do not talk to the pt as if he’s still alive

23. Organ donation Call regional transplant coordinator for all deaths  Donor or not in your eyes  Tissue – bone, corneas, heart valves Do not mention organ donation to family  “LifeLink” will approach them after the child is declared If family asks you about donation  Acknowledge that it is a wonderful gift they are considering  Tell them you will contact “LifeLink” to have them available for questions  Contact “LifeLink” ASAP