Title: Determination of Brain Death<br/>Author: Feras Khan<br/><a href='http://umem.org/profiles/faculty/1145/'>[Click to email author]</a><hr/><p style="font-family: arial, sans-serif; font-size: 13px;">
        <strong><span style="font-family: Arial, Verdana, sans-serif; font-size: 12px;">Determination of Brain Death</span></strong></p>
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        <ul>
                <li>
                        With the recent media spotlight on brain death (irreversible end of brain activity) due to a few recent cases, it would be helpful to review the definition.</li>
                <li>
                        Rule out alternative causes including hypothermia, drug-induced coma, metabolic abnormalities, or severe electrolyte disturbances.</li>
                <li>
                        A clear irreversible cause must be known based on history and diagnostic studies.</li>
        </ul>
        <p>
                <strong>Clinical Examination</strong></p>
        <ul>
                <li>
                        Patient should be unresponsive to verbal or noxious stimulation, with the exception of spinally mediated responses.</li>
                <li>
                        Absence of brainstem Reflexes</li>
        </ul>
        <ol>
                <li>
                                    No pupillary response</li>
                <li>
                                    Absent corneal reflex</li>
                <li>
                                    Absent gag and cough reflex</li>
                <li>
                                    Absent cervico-ocular reflex (Doll’s Eyes Maneuver)</li>
                <li>
                                    Absent vestibulo-ocular reflex (Cold Calorics)</li>
        </ol>
        <ul>
                <li>
                        Apnea Testing  (disconnecting the ventilator and evaluating respiratory drive)</li>
        </ul>
        <p>
                If apnea testing cannot be performed due to instability, hypoxia, or cardiac arrhythmias, then a confirmatory test should be performed (from highest to lowest sensitivity):</p>
        <ul>
                <li>
                         Angiography (lack of intracranial flow)</li>
                <li>
                          EEG</li>
                <li>
                          Transcranial Doppler</li>
                <li>
                          Technetium-99 brain scan</li>
                <li>
                          Somatosensory evoked potentials</li>
        </ul>
        <p>
                There is state to state variation on who can perform the test and how many separate examinations need to be performed before brain death can be legally declared.</p>
        <p>
                For a great review on some of the pitfalls in making the diagnosis and difficulties with the examination, please see the attached article. </p>
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         </p>
<fieldset><legend>References</legend>

                <div style="font-size: 0.8465em; line-height: 1.45em; font-family: arial, helvetica, clean, sans-serif;">
        <span role="menubar"><a aria-expanded="false" aria-haspopup="" href="http://www.ncbi.nlm.nih.gov/pubmed/11309637#" role="menuitem" style="color: rgb(102, 0, 102); border-bottom-width: 0px;" target="_blank" title="The New England journal of medicine.">N Engl J Med.</a></span> 2001 Apr 19;344(16):1215-21.</div>
<h1 style="font-size: 1.231em; margin: 0.375em 0px; line-height: 1.125em; font-family: arial, helvetica, clean, sans-serif;">
        The diagnosis of brain death.</h1>
<div style="font-size: 0.923em; font-family: arial, helvetica, clean, sans-serif;">
        <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Wijdicks%20EF%5BAuthor%5D&cauthor=true&cauthor_uid=11309637" style="color: rgb(102, 0, 102); border-bottom-width: 0px;" target="_blank">Wijdicks EF</a>.</div>
</fieldset><fieldset><legend>Attachments</legend>
                        pitfalls_in_brain_death,_wijdicks.pdf (93 Kb)<br/><a href='http://umem.org/files/uploads/1401141409_pitfalls_in_brain_death,_wijdicks.pdf' target='_blank'>http://umem.org/files/uploads/1401141409_pitfalls_in_brain_death,_wijdicks.pdf</a><br/><br/></fieldset>