BRAIN DEATH CRITERIA

Kristen Luttenberger APN-C, RN, MSN, CCRN-CMC, PCCN

www.howtofascinate.com

The History

Animal Studies-1942

Mollaret and Gouloon (1959) described “depasse”

Harvard Criteria-Published 1968 defined irreversible coma (JAMA)

Karen Ann Quinlan controversy-1976 Uniform Determination of Death Act (UDDA)-1981

Unreceptivity and unresponsiveness No movement or breathing No reflexes Flat electroencephalogram (confirmatory-no drugs or hypothermia)

Karen Ann Quinlan March 29th 1954-June 11th 1985

http://en.wikipedia.org/wiki/Karen_Ann_Quinlan

Uniform Determination of Death Act (UDDA)-1981 An individual who has sustained either:

(1) irreversible cessation of circulatory and respiratory functions, or

(2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with “accepted medical standards”

American Academy of Neurology

1995

http://journals.neurology.org/site/images/ncp_current_issue.png

http://www.neurology.org/content/by/year

Clinical Findings: Coma with cause Absence of brainstem reflexes Apnea

#1 Diagnosing Coma Prerequisites:

Determine the cause of coma by history, examination, neuroimaging, and laboratory testing.

No drugs on board

Normothermia

Normotensive

No severe electrolyte or endocrine disturbances

http://www.brainline.org/images/uploads/orig/2010/00667.jpg

#1 Diagnosing Coma Patients must lack all

evidence of responsiveness

No eye opening or eye movement to noxious stimuli

Noxious stimuli should not produce a motor response other than spinally mediated reflexes

http://what-when-how.com/wp-content/uploads/2012/04/tmp2628_thumb2.jpg

#2 Absence of Brainstem Reflexes

Cranial Nerve General Function I-Olfactory Sense of Smell

II-Optic Sight

III-Oculomotor Eye Movement

IV-Trochlear Eye Movement

V-Trigeminal Face: sensory/motor

VI-Abducens Eye Movement

VII-Facial Facial expression & sensory

VIII-Vestibulocochlear Hearing & Balance

IX-Glossopharyngeal Tongue & Throat-motor & sensory

X-Vagus Parasympathetic

XI-Accessory Head, neck, shoulder movement & swallowing

XII-Hypoglossal Speech, chewing and swallowing

#2 Absence of Brainstem Reflexes

Pupillary Response

Pupils should be fixed in a midsize or dilated position (4-9mm)

Constricted pupils may suggest drug intoxication

No pupillary response to light (Cranial nerves II, III)

http://remodelingclay.com/wp-content/uploads/2013/04/Dilated_Pupils-4.jpg

#2 Absence of Brainstem Reflexes

Oculocephalic Reflex(Dolls Eyes)

Cranial Nerves III, IV, VIII bettermedicine.com

#2 Absence of Brainstem Reflexes

Oculovestibular Reflex-CN-III, IV, VI, VIII

No eye movement with brain death http://www.wikilectures.eu/images/3/30/Vestibulo_ocular_reflex.jpg

#2 Absence of Brainstem Reflexes

Corneal Reflex-CN-III, V, & VII

http://meded.ucsd.edu/clinicalmed/eye_corneal_reflex.jpg

#2 Absence of Brainstem Reflexes

Pharyngeal (gag) reflexes Tracheal reflexes

http://www.jaaos.org/content/11/4/221/F1.large.jpg

CN- IX & X

Brain Reflexes vs. Spinal Reflexes??

Sensory stimulus can arise from receptors in the muscle, joints, and skin resulting in motor response that is ENTIRELY within the spinal cord.

Plantar flexion

Finger , leg, or head movements

Pupillary Changes

Facial Twitching

blog.billhurst.com

#3 Apnea Test-CO2 Challenge

Prerequisites:

Normotensive-SBP>100

Normothermia-T>36C

Euvolemia

Eucapnia (ABG)

Absence of hypoxia

No prior evidence of CO2 retention

http://authorstream.s3.amazonaws.com/content/1631894_634926230487388750.jpg

#3 Apnea Test-CO2 Challenge Procedure: Preoxygenate at least 10

minutes with 100% to a PaO2 of >200

Reduce ventilator frequency to 10 breaths per minute

Reduce PEEP to 5cmH2O

If SaO2>95% perform baseline ABG

Disconnect ventilator

Preserve O2

Watch for respirations for 8-10minutes, if none repeat ABG

http://i923.photobucket.com/albums/ad74/savingthebrain/anatomy/braindeath.jpg

#3 Apnea Test-CO2 Challenge Conclusion: Abort if SBP<90mmHg or

SaO2<85% for >30secs.

Can retry procedure with T-piece, CPAP-10cmH2O, and 100% O2-12L/min.

If respiratory movements are absent and PaCo2>60mmHg or 20mmHg over baseline then apnea test is positive which supports clinical diagnosis of brain death.

If inconclusive but patient is stable, may repeat for 10-15 minutes after pre-oxygenation.

http://31.media.tumblr.com/047147195794156841af54e03a9c8cb4/tumblr_n3ur9tzRfQ1rog5d1o1_1280.jpg

To provide an update of the 1995 American Academy of Neurology guideline with regard to the following questions…

Systemic literature search of MEDLINE and EMBASE FROM January 1996 to May 2009 age 18 or older.

2010 http://blogpinali.files.wordpress.com/2010/07/aan.jpg

Question #1 Are there patients who fulfill

the clinical criteria of brain death protocol who recover neurologic function??

NO http://b-i.forbesimg.com/work-in-progress/files/2013/08/0714_brain-idea_300x30031.jpg

Question #2

What is an adequate observation period to ensure that cessation of neurologic function is permanent?

???? http://www.2020site.org/riddles/images/printablebrainteaser.jpg

Question #3

Are complex motor movements that falsely suggest retained brain function sometimes observed in brain death?

YES!! http://blogs-images.forbes.com/work-in-progress/files/2012/11/brain-puzzle.jpg

Question #4 What is the comparative

safety of techniques for determining apnea?

http://www.free-for-kids.com/Brain%20Teasers/welcome-brain-teasers.jpg

SAFE!! BUT…

Question #5

Are there new ancillary tests that accurately identify patients with brain death?

(MRI, CT angiography, Somatosensory evoked potentials, BIS)

http://sharpbrains.com/wp-content/uploads/2013/03/bigstock-Thinker-31113506.jpg

NO!!

Criteria for Confirmatory Tests

AAN states that : “In adults, ancillary tests are not needed for the clinical diagnosis of brain death and cannot replace a neurologic examination.”

However: “Confirmatory tests are desirable in patients whom specific components of clinical testing cannot be reliably performed or evaluated.”

MRI/MRA in Brain Death

Diffusion weighted MRI specific criteria and findings on MRI/MRA related to brain death

http://www.researchgate.net/publication/230850664_Imaging_findings_of_brain_death_on_3-tesla_MRI

CT Angiography of head

http://www.ajnr.org/content/30/8/1566.long

CT Angiography in Brain Death

http://www.ajnr.org/content/30/8/1566.long

Somatosensory Evoked Potentials

http://www.neuroicu.info/neurophysiologicmonitoring.htm

BIS-Bispectral Index

http://www.covidien.com/imageServer.aspx/doc252087.pdf?contentID=32980&contenttype=application/pdf

Oldies but Goodies??

EEG

http://openi.nlm.nih.gov/detailedresult.php?img=1190185_1471-2377-5-14-6&req=4

Cerebral Angiography

www.donorrecovery.org

Brain Scan (Cerebral Scintigraphy)

http://link.springer.com/static-content/images/633/chp%253A10.1007%252F978-1-4614-1997-6_95/MediaObjects/978-1-4614-1997-6_95_Fig5_HTML.gif

Brain Scan (Cerebral Scintigraphy)

http://ccn.aacnjournals.org/content/33/6/27/F5.large.jpg

“Hollow Skull Phenomenon”

Transcranial Doppler

http://www.dwl.de/fixfoxdateien/galerie/testordner/hirntod_02.jpg http://ultramedco.com/eme264B.jpg

Brain Death World Wide Legal standards on organ

transplantation-55/80

Practice guidelines for brain death in adults-70/80

More than one physician required to declare brain death >50%

Apnea test using CO2 target recommended-59%

Differences in time of observation & required expertise of examining physician

Confirmatory testing was mandatory in 40% of practice guidelines

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Brain Death World Wide

New York & New Jersey

http://www.mormonnewsroom.org/article/introduction-religious-freedom

Alaska & Georgia

Brain Death World Wide

Bangladesh Iran

http://www.operationworld.org/files/ow/maps/lginset/bang-LMAP-md.png

3 Different physician observers and one has to be at least an associate professor in academic rank.

12, 24, & 36-hour observation by 3 different physicians

Brain Death World Wide Japan Indonesia

CT scan detects “irreparable lesions” Known cause of cardiac arrest Ciliospinal reflex performed Apnea test after loss of 7 brainstem reflexes & a isoelectric EEG Intact tympanic membrane Children <6 excluded

http://www.worldatlas.com/webimage/countrys/asia/idas.gif

3 medical doctors Lawyer should be present as an observer to determine brain death

Thank You!!!

Arbour, RB. (2013) Brain Death: Assessment, Controvery, and Confounding Factors. Critical Care Nurse 33(6); 27-47

Hills, TE. (2010) Determining brain death. www.Nursing2010.com. 34-40.

Wijdicks, E. (2002) Brain death worldwide. Neurology 58;20-25

Wijdicks, E. (2010) The case against confirmatory tests for determining brain death in adults. Neurology 75;77-83

Wijdicks E., Panayiotis NV, Gronseth GS, & Greer DM. (2010) Evidence-based guideline update: Determining brain death in adults. Neurology 74;1911-1918