brain death criteria - a & t...
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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
http://i.telegraph.co.uk/multimedia/archive/01806/earth_1806334c.jpg
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