Brain death
Introduction
• Death is an irreversible, biological event that
consists of permanent cessation of the critical
function of the organism as a whole,
especially respiration and heart beat.
• Brain death is an irreversible form of
unconsciousness characterized by a loss of
brain function while the heart continuous to
beat.
History- Earliest human history
Neurological failure
(COMA)
Death
Cardiac failure Respiratory failure
(Absent Pulse, HR) (Absent air entry and exit)
History- Modern concept
Modern concept is the extension of the
earliest concept
Failure of the cardio-respiratory system that
transports chemical and nutrients
▼
Death of brain tissue
▼
Stops cardio-respiratory system
History- Modern
concept…
• The loss of consciousness proceeds the
respiratory and cardiopulmonary failure.
• Death of brain results in death of all other
organs.
Command
Brain cells
Come on let’s go
sweet heart …
Coordinate
Communicate
Dilemma!!!!!
• The functions of brain cells can be taken over
by the technology even after the brain death.
Supporting
life v/s
Acorpse with beating
heart
There is a
need…!!!
• To define death.
• To determine a point on the timeline of death
process that defines no return to life.
• To harvest the organs before the destruction.
death
Death
Coma
Brain
Brain anatomy
Brain
• Cerebrum
anatomy…
– Controls memory, consciousness and higher mental
functioning
• Cerebellum
– Controls various muscle functions
• Brain stem consisting of the midbrain, pons, and
medulla, which extends downwards to become the
spinal cord
– Controls respiration and various basic reflexes (e.g.,
swallow and gag)
Brain death – definition
• The legal definition of the condition varies in
different courtiers.
US: Complete and irreversible cessation of the
whole brain activity including the brain stem.
UK: Complete and irreversible cessation of the
activity of brain stem.
Whole brain death v/s Brain stem death
• The difference lies in the results of testing.
• In Brain Stem Death there are instances where
blood succeeds in reaching other areas of the
cortex and there can be measurable electrical
tracings as indicated by an EEG.
• This is not necessarily indicative of brain function
but rather that some cells have electrical activity.
• Even with this activity, if the patient is brain-stem
dead, there is no chance of recovering
consciousness or breathing.
Brain death- India
• The usual clinical criteria for brain death
include the absence of brain stem reflexes
including the spontaneous respiration
requiring mechanical ventilation or life
support to continue cardiac function.
Brain death
Coma (with a
known
cause)
Absence of
Apnoea brainstem
reflexes
Pre-requisites
Evaluation should include clinical and
neurological imaging evidences at,
• Body temperature > 36° C
• Normal Systolic BP ( > 100 mm Hg)
The process of brain death certification
1)Inclusion
2)Exclusion
3)Examination
4)Confirmation
5)Documentatio
n
The process of brain death certification
1)Identification of history or physical
examination findings that provides a clear
etiology of brain dysfunction.
– Severe head injury
– Hypertensive intracerebral hemorrhage
– Aneurysm, SAH
– Hypoxemic-ischemic brain injury
– Fulminant hepatic failure
The process of brain death certification..
2)Exclusion of conditions that might confound the
subsequent examinations of cortical or brain stem
function.
– Shock/ hypotension
– Drug known to alter neurological, neuromuscular
functions and EEG testing (anesthetics,
neuroparalytics, alcohols).
– Brain stem encephalitis.
– GBS Syndrome.
– Encephalopathy associated with hepatic failure.
– Severe hypophosphatemia.
The process of brain death certification..
3)Performance of complete neurological
examination (diagnostic testing)
– Establish Coma
– Establish Absence of Brain Stem
Reflexes
– Establish Apnea (Absence of Respiration
drive)
4)Ancillary testing (confirmatory testing)
5)Documentation
– Time of death is the time the arterial PaCO2
reached the target value
OR
Determination of brain death
COMA
• Establish No response to noxious stimulus
– Nail Bed pressure
– Sternal Rub
– Supra Orbital Ridge Pressure
GLASGOW COMA SCALE (GCS)??
• E1 V1 M1 = 3
Determination of brain death…
Absent Brain Stem Reflexes
• Pupillary Reflex (absent)
• Eye Movements
– Occulo-Cephalic ( Dolls Eye Movements)
– Occulo-Vestibular (Cold Caloric test)
• Facial Sensation and Motor Response
• Pharyngeal (Gag) Reflex absent
• Tracheal (Cough) Reflex Absent
Pupillary Reflex
Normal
• In healthy persons, both pupils are normally
equally wide; they narrow when exposed
to light.
• Brain-dead patients lack this reflex; their
pupils are no longer reactive to light.
• Pupils dilated with no constriction to bright
light single beam of light.
Brain death
Corneal reflex
• When the outer layer of the eye (cornea)
comes in contact with a foreign object, the
eyes close as an automatic reflex.
• When the physician tests this reaction by
touching the cornea of a brain-dead patient
with a cotton swab, this reflex is absent.
Eye Movements
Occulo-Cephalic ( Dolls Eye Movements)
• Brisk turning or tipping of head cause slow eye
movement in the opposite direction.
• The eyes of a brain dead patient however do
not react to this test and remain in their initial
position.
A positive Doll’s
eye indicates an
intact brain stem
Eye Movements
Occulo-Vestibular (Cold Caloric test)
• Rule for direction of nystagmus
A positive
Cold Caloric
test indicates
an intact brain
stem
Facial Sensation and Motor Response
• Response to pain in the face.
• Even patients who are in deep coma respond
to painful stimuli that are applied to the face
with distinguishable twitching of the
muscles and defense reactions of the head
and neck muscles.
• Brain-dead patients lack these reflexes.
Brain death
Pharyngeal (Gag) Reflex absent &
Tracheal (Cough) Reflex Absent
• Gag- and cough reflex (tracheal and
pharyngeal reflex): Touching the back of the
pharynx induces a gag reflex in healthy and
unconscious persons. This reflex is absent in
brain-dead patients.
Brain Death : Apnea Test
• Pre-requisites
– Body Temperature > 36° C
– Systolic Blood Pressure ≥ 100 mm Hg
– Normal Electrolytes profile
– Normal PaCO2 (35-45 mm Hg)
• Pre-Oxygenation
– 100% Oxygen via Tracheal Cannula for 10 min
– monitor SpO2
Apnea Test…
• Reduce Ventilation frequency to 10/min
• Reduce PEEP to 5 Cm H2O
• Take 1st Blood sample for Blood Gas
analysis
• Disconnect Ventilator
• Deliver 100% O2 by catheter through ET
tube
@ 6 L/min
• Observe for Respiratory Movement
– At least for 8 – 10 min
Apnea Test….
• If no respiratory drive observed after 08 min.
– Take next Blood sample for Blood gas studies
Respiratory
– Reconnect ventilator. movements
• Discontinue Testing →test
negative
– If BP drops to < 90 mm Hg
– SpO2 ↓ to 85% by pulse Oxymetry for 30 Sec
Test is positive if,
• If respiratory movements are absent & arterial PaCO2 is
60 mm Hg or more.
• 20 mm Hg ↑ in baseline normal PaCO2.
Supports the clinical diagnosis of brain death.
Brain Death
Ancillary Confirmatory Testing
• Recommended when
– Proximate cause of coma is not known
– Apnea testing inconclusive or aborted or
– When confounding clinical conditions limit clinical
examination
• EEG
• Cerebral Angiography
• PET : Glucose Metabolic Studies
• Dynamic Nuclear Scan
• Somato-Sensory Evoked Potential
Positive ancillary tests
EEG Cerebral angiography
Electro-cerebral silence Normal Brain death
Glucose metabolism studies PET
Blood flow
Who declares Brain death?
• Assessed by 2 physicians**
**should not be from the transplant unit.
**one of them must be a consultant.
Declaration done by,
• Medical Superintendent of the hospital
• An independent Medical Practitioner nominated by the
Medical Superintendent of the Hospital.
• A Neurologist or Neurosurgeon nominated by the
Medical Superintendent of the Hospital/AACT
• The doctor on-duty treating
Examination timings
2 brain stem reflex tests and 1 apnea test.
• Neonates – 2days apart with 2 EEG.
• Children >2months – 1 day apart with 1 EEG.
• Children >1 years – 12 hours apart with 1 EEG.
• Adults – 6 hours apart, EEG is confirmatory.
Brain Death : India
• Transplantation of Human Organs act, 1994
• Highlights:
– Statutory sanction to the Brain Death Concept
– Regulation of Removal, Storage and
Transplantation of human organs for therapeutic
purposes
– Commercial dealings in human organs prevented
Lazarus sign
• Biblical character, Jesus restored Lazarus to
life four days after his death.
• Or Lazarus reflex is a reflex movement
in brain-dead patients, which causes them to
briefly raise their arms and drop them crossed
on their chests.
• may prevent delays in brain-dead diagnosis
and misinterpretation.
Can a person wake up from brain
stem death?
• No patient that was ever diagnosed brain-
stem dead by adequate criteria has ever
woken up from brain-stem death.
• Even though the heart now continues to beat
because it is artificially being supplied with
oxygen (by means of ventilator), ultimately
there will be complete systemic failure and
the heart will stop beating, usually within a
few days.
Role of a nurse????
• Early detection of brain death.
• Identification of reflexes.
• Assisting in determination process.
• Documentation of the events.
• Proper communication.
• Psychological support to the family.
• Initiatives for organ donation counseling.
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
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 patient as if he’s still
alive.
