Brain Death

Question 1

Definition of a coma

Answer 1

Eyes do not open spontaneously or to external stimulation
Does not follow any commands
Does not mouth or utter recognisable words
Does not demonstrate intentional movement
Cannot sustain visual pursuit of eyes through 45 degree arc in any direction when eyes are held open manually

Question 2

Glasgow Coma Scale - most alert score

Answer 2

15

Question 3

Glasgow Coma Scale - least alert score

Answer 3

3

Question 4

Locked-in Syndrome

Answer 4

Aware and awake
Able to breathe
Damage to ventral pons
Can communicate by blink or eye movement
Can feel pain, touch and position of limbs
No cure
Usually a result of brainstem stroke
Recovery rare

Question 5

Vegetative state

Answer 5

No evidence of:
Awareness of self or environment, or ability to interact with others
Sustained purposeful or voluntary behaviours either spontaneously or in response to stimuli in any sensory modality
Language, comprehension or meaningful expression

Can make small movements or noises, e.g. laugh, shout, but not in response. May also have a sleep/wake cycle

Question 6

Persistent Vegetative State (PVS)

Answer 6

Diagnosed if no change at 30 days
50% chance of improvement within 6 months, though the vast majority remain severely disabled
Published instances of improved abilities with neurostimulants
Not legally recognised as death

Question 7

PDOCs

Answer 7

Persistent Disorders of Consciousness
Includes, coma, PVS and MCS (Minimally Conscious State - severely altered consciousness, reproducible but inconsistent response)

Question 8

Ethical and legal issues with PVS

Answer 8

Very difficult to be certain of diagnosis

How can you rule out awareness?

Question 9

PDOC Assessment

Answer 9

Gold standard assessment is the SMART Assessment (Sensory Modality Assessment and Rehabilitation Techniques)

Question 10

SMART Assessment

Answer 10

Sat upright
As medically well as possible
5-10 minutes of observation
Standardised stimuli including pictures, sounds, lights, smells, tastes, family etc.
Repeated around 10 times over weeks
Analysed for repeated/consistent reactions

Question 11

SMART Assessment Levels

Answer 11

1: No response to any stimulus
2: Reflex response
3: Withdrawal response (turning head or eyes away or withdrawing limbs)
4: Localising response (turn head or move towards stimuli)
5: Differentiating response (follow commands, use object appropriately)

Question 12

Brainstem death

Answer 12

Unable to breathe and unconscious
Destroyed reticular formation
No electrical activity
No clinical evidence of brain function

Question 13

Preconditions for brainstem death

Answer 13

Diagnosis compatible with brainstem death, presence of irreversible structural brain damage, apnoeic

Question 14

Exclusions for brainstem death

Answer 14

Drug effects, hypothermia, metabolic abnormalities, endocrine abnormalities, intoxication

Question 15

Clinical tests for brainstem death

Answer 15

Absent brainstem reflexes (pupils, corneal, no motor response in cranial nerves, gag, cough, vestibule-ocular)
Persistent apnoea
2 practitioners (one consultant) on 2 occasions