Scientific evaluation of brain death

Question 1

How do you confirm brain death with imaging?

Answer 1

Complete absence of blood flow

Question 2

What is the name of the norwegian doctor who survived death under the lake?

Answer 2

Anna Bogenholm

Question 3

What are the prerequisites for brain death testing?

Answer 3

1. Cause of coma known and irreversible
2. Temperature >35 degrees C >24h
3. Normal BP (SBP >90, MAP >60)
4. Exclusion of all drugs effects
5. No metabolic/endocrine cause for the coma
   Ensure
   - normal PCO2 <6kPa (45mmHg)
   - normal PO2 >8kPa (60mmHg)
   - pH >7.25
   - glucose 3-20mmol/L
   - Na 115-160mmol/L
   - K >2mmol/L
   - Mg 0,5 - 3mmol/L
   - PO4 05 - 3mmol/L
   - normal thyroid
   - normal cortisol

Question 4

Which drugs can mimic a brain dead state?

Answer 4

Opiates
BZDs
Barbiturates
NM blockers
Anticholinergics

Question 5

What time is defined as a drug no longer having a residual effect?

Answer 5

4 times drug half life

Question 6

How do you perform brain death testing

Answer 6

1. Assess for any responsiveness
2. Apply noxious stimuli in CN distribution to 4 limbs and trunk to observe for motor response
3. Brainstem testing
   - pupillary light reflex
   - corneal reflex
   - pharyngeal gag reflex
   - cough reflex
   - oculovestibular reflex
   Other
   - facial movement in response to painful stimuli
   - oculocephalic reflex
   - oculocardiac reflex
   - CNX control over HR
4. Apnoea test

Question 7

How can you test for motor response in brain death testing?

Answer 7

Pressure over supraorbital nn
Sternal rub
Deep nailbed pressure
These equate to GCS 3 (2T)

Question 8

Seizure activity does not preclude the determination of brain death
True or false?

Answer 8

False

Question 9

Can cough reflex be assessed in patient’s with high spinal cord injury?

Answer 9

No

Question 10

What is the oculovestibular reflex also known as?

Answer 10

Cold caloric reflex

Question 11

How do you test the oculovestibular reflex?

Answer 11

1. Head to 30 degrees

2. 50ml ice cold water injected down EAC onto tympanic membrane

Question 12

How do you perform the apnoea test?

Answer 12

1. Test BGA
   - O2, CO2 and pH must all be normal
2. 100% O2 >5min
   3, Disconnect from ventilator and observe for spontaneous ventilation while still suppling O2 via
   - TPs every 15s
   - suction catheter in ET tube at 6L/min
3. If CO2 risen to 6.6kPa/50mmHg patient is clinically brain death
4. Brain death declared at time of BGA

Question 13

When is the brain death determined after apnoea test declared?

Answer 13

Time of arterial blood gas analysis

Question 14

How do you test the control of vagus nerve over the heart rate?

Answer 14

Give 0.04mg/kg atropine to increase heart by 5pm or 10% increase from baseline

Question 15

What is the oculocardiac reflex?

Answer 15

Pressure on eyeball -> decrease in BP and HR

Question 16

What is the oculocephalic reflex?

Answer 16

Reflex to keep object’s in our visual field

Question 17

What is the oculocephalic reflex also known as?

Answer 17

Doll’s eye reflex

Question 18

What are the most widely validated tests for brain death?

Answer 18

Cerebral angiography
Nucleotide scanning

Other

• transcranial doppler studies
• CT angiography
• MRI angiography
• EEG

Question 19

What is four vessel cerebral angiography?

Answer 19

A series of x-rays is taken visualizing the blood flow in the brain

1. A catheter is advanced up from the femoral or brachial artery, and the X-ray guidance into the aortic arch
2. Contrast is then directly injected into the arterial system, and a series of real time X-rays taken
3. The blood flow of both the carotid and the vertebral arteries is seen, and followed into the anterior and the posterior cerebral circulation

Question 20

Why are the vessels not seen in a cerebral angiography of a brain dead patient?

Answer 20

Contrast cannot enter the skull due to the increased pressure

Question 21

What is the preferred ancillary testing method of brain death in children?

Answer 21

Radionucleotide imaging