brain death -dr. cohen
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Brain DeathBrain Death
Anatomy and PhysiologyAnatomy and Physiology
Joel S. Cohen, M.D.Joel S. Cohen, M.D.Associate Professor of Clinical NeurologyAssociate Professor of Clinical Neurology
Albert Einstein College of MedicineAlbert Einstein College of Medicine
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Historical PerspectiveHistorical Perspective
Prior to the advent of mechanicalPrior to the advent of mechanicalrespiration, death was defined as therespiration, death was defined as thecessation of circulation and breathingcessation of circulation and breathing
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Historical PerspectiveHistorical Perspective
19591959 Coma depasseComa depasse Mollaret and GoulonMollaret and Goulon
19681968 Irreversible Coma/Brain DeathIrreversible Coma/Brain Death Harvard MedicalHarvard MedicalSchool Ad Hoc CommitteeSchool Ad Hoc Committee
1981 Uniform Determination of Death Act1981 Uniform Determination of Death Act -- PresidentsPresidentsCommission for the Study of Ethical Problems in MedicineCommission for the Study of Ethical Problems in Medicine
1994 American Academy of Neurology Guidelines for the1994 American Academy of Neurology Guidelines for thedetermination of Brain Deathdetermination of Brain Death
2005 NYS Guidelines for Determining Brain Death2005 NYS Guidelines for Determining Brain Death
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Brain Death Current ConsensusBrain Death Current Consensus
Absent Cerebral FunctionAbsent Cerebral Function
Absent Brainstem FunctionAbsent Brainstem Function
ApneaApnea
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Normal Brain AnatomyNormal Brain Anatomy
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Normal Brain AnatomyNormal Brain Anatomy
Cerebral Cortex
Brain Stem
Reticular
Activating
System
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Cerebral CortexCerebral Cortex
CognitionCognition
Voluntary MovementVoluntary Movement
SensationSensation
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Brain StemBrain Stem
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Brain StemBrain Stem
MidbrainCranial Nerve III
pupillary function
eye movement
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Brain StemBrain Stem
Pons
Cranial Nerves IV, V, VI
conjugate eye movement
corneal reflex
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Brain StemBrain Stem
MedullaCranial Nerves IX, X
Pharyngeal (Gag) Reflex
Tracheal (Cough) Reflex
Respiration
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eticular ActivatingReticular Activating
SystemSystem
Receives multipleReceives multiplesensory inputssensory inputs
MediatesMediateswakefulnesswakefulness
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Causes of Brain DeathCauses of Brain Death
Normal Cerebral Anoxia
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Causes of Brain DeathCauses of Brain Death
Normal Cerebral Hemorrhage
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Causes of Brain DeathCauses of Brain Death
Normal Subarachnoid Hemorrhage
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Causes of Brain DeathCauses of Brain Death
Normal Trauma
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Causes of Brain DeathCauses of Brain Death
Normal Meningitis
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Mechanism of Cerebral DeathMechanism of Cerebral Death
Neuronal Injury
Decreased IntracranialBlood Flow
Neuronal Swelling
Increased IntracranialPressure
ICP>MAP isincompatible
with life
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Conditions Distinct FromConditions Distinct From
Brain DeathBrain Death
Persistent Vegetative StatePersistent Vegetative State
LockedLocked--in Syndromein Syndrome
Minimally Responsive StateMinimally Responsive State
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Persistent Vegetative StatePersistent Vegetative State
Normal SleepNormal Sleep--Wake CyclesWake Cycles
No Response to Environmental StimuliNo Response to Environmental Stimuli
Diffuse Brain Injury with PreservationDiffuse Brain Injury with Preservationof Brain Stem Functionof Brain Stem Function
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LockedLocked--in Syndromein Syndrome
Ventral Pontine Infarct
Complete Paralysis
Preserved Consciousness
Preserved Eye Movement
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Minimally Responsive StateMinimally Responsive State
Diffuse or MultiDiffuse or Multi--Focal Brain InjuryFocal Brain Injury
Preserved Brain Stem FunctionPreserved Brain Stem Function
Variable Interaction withVariable Interaction withEnvironmental StimuliEnvironmental Stimuli
Static Encephalopathy
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Brain Death NeurologicalBrain Death Neurological
ExaminationExaminationClinical Prerequisites:Clinical Prerequisites:
Known Irreversible CauseKnown Irreversible Cause
Exclusion of Potentially Reversible ConditionsExclusion of Potentially Reversible Conditions Drug Intoxication or PoisoningDrug Intoxication or Poisoning
Electrolyte or AcidElectrolyte or Acid--Base ImbalanceBase Imbalance
Endocrine DisturbancesEndocrine Disturbances
Core Body temperature > 32Core Body temperature > 32 CC
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Brain Death NeurologicalBrain Death Neurological
ExaminationExamination
ComaComa
Absent Brain Stem ReflexesAbsent Brain Stem Reflexes
ApneaApnea
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ComaComa
No Response to Noxious StimuliNo Response to Noxious Stimuli
Nail Bed PressureNail Bed Pressure
Sternal RubSternal Rub
SupraSupra--Orbital Ridge PressureOrbital Ridge Pressure
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Absence of Brain StemAbsence of Brain Stem
ReflexesReflexes Pupillary ReflexPupillary Reflex
Eye MovementsEye Movements
Facial Sensation and Motor ResponseFacial Sensation and Motor Response
Pharyngeal (Gag) ReflexPharyngeal (Gag) Reflex
Tracheal (Cough) ReflexTracheal (Cough) Reflex
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Pupillary ReflexPupillary Reflex
Pupils dilated with no constriction to bright light
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Eye MovementsEye Movements
Occulo-Cephalic Response
Dolls Eyes Maneuver
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Eye MovementsEye Movements
Oculo-Vestibular Response
Cold Caloric Testing
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Facial Sensation andFacial Sensation and
Motor ResponseMotor Response Corneal ReflexCorneal Reflex
Jaw ReflexJaw Reflex
Grimace to Supraorbital orGrimace to Supraorbital or
TemporoTemporo--Mandibular PressureMandibular Pressure
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Apnea TestingApnea Testing
PrerequisitesPrerequisites
Core Body Temperature > 32Core Body Temperature > 32 CC
Systolic Blood Pressure 90 mm HgSystolic Blood Pressure 90 mm Hg
Normal ElectrolytesNormal Electrolytes
Normal PCO2Normal PCO2
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Apnea TestingApnea Testing
1. Pre1. Pre--OxygenationOxygenation
100% Oxygen via Tracheal Cannula100% Oxygen via Tracheal Cannula
PO2 = 200 mm HgPO2 = 200 mm Hg
2. Monitor PCO2 and PO2 with pulse oximetry2. Monitor PCO2 and PO2 with pulse oximetry
3. Disconnect Ventilator3. Disconnect Ventilator
4. Observe for Respiratory Movement until PCO2 =4. Observe for Respiratory Movement until PCO2 =60 mm Hg60 mm Hg
5. Discontinue Testing if BP < 90, PO2 saturation5. Discontinue Testing if BP < 90, PO2 saturationdecreases, or cardiac dysrhythmia observeddecreases, or cardiac dysrhythmia observed
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Confounding ClinicalConfounding Clinical
ConditionsConditions Facial TraumaFacial Trauma
Pupillary AbnormalitiesPupillary Abnormalities
CNS Sedatives or Neuromuscular BlockersCNS Sedatives or Neuromuscular Blockers
Hepatic FailureHepatic Failure
Pulmonary DiseasePulmonary Disease
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Observations CompatibleObservations Compatible
with Brain Deathwith Brain Death Sweating, BlushingSweating, Blushing
Deep Tendon ReflexesDeep Tendon Reflexes
Spontaneous Spinal ReflexesSpontaneous Spinal Reflexes-- Triple FlexionTriple Flexion
Babinski SignBabinski Sign
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Confirmatory TestingConfirmatory Testing
Recommended when the proximateRecommended when the proximatecause of coma is not known or whencause of coma is not known or whenconfounding clinical conditions limitconfounding clinical conditions limitthe clinical examinationthe clinical examination
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Confirmatory TestingConfirmatory Testing
EEG
Normal Electrocerebral Silence
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Confirmatory TestingConfirmatory Testing
Cerebral AngiographyCerebral Angiography
Normal No Intracranial Flow
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Confirmatory TestingConfirmatory Testing
TechnetiumTechnetium--99 Isotope Brain Scan99 Isotope Brain Scan
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Confirmatory TestingConfirmatory Testing
MRMR-- AngiographyAngiography
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Confirmatory TestingConfirmatory Testing
Transcranial Ultrasonography
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Confirmatory TestingConfirmatory Testing
Somatosensory Evoked PotentialsSomatosensory Evoked Potentials
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Concern for man and his fate mustConcern for man and his fate must
always form the chief interest of allalways form the chief interest of all
technical endeavors. Never forgettechnical endeavors. Never forgetthis in the midst of your diagramsthis in the midst of your diagrams
and equations.and equations.
Albert EinsteinAlbert Einstein