Brain death: Difference between revisions

(changes per neurocritical care - fontera)
(Neurocritical care edit)
Line 24: Line 24:
# Prerequisites:
# Prerequisites:
##Clinical Criteria
##Clinical Criteria
###Must be diagnosis compatabile with brain death (SAH/ICH/TBI etc.)
##Core temp >32 C (actual temp value > 32 varies by institution) with corrected electrolytes. > 36.5C is preferred.
##Core temp >32 C (actual temp varies by institution) with corrected electrolytes. > 36.5C is preferred.
##Exclusion of iatrogenic drug effects
###check urine tox fo ropiates or benzodiazepines and illicit drugs. Review med rec for sedating/paralytic meds (recent intubation/propofol infusion etc).
####if drug cannot be quantified. Patient observed for 4x half life of drug  (drug levels ~5% of previous)
##SBP >90
##SBP >90
##Nl PCO2 (>40)
##Nl PCO2 (>40)
##Nl PO2 (preoxiginate >200)
##Nl PO2 (preoxiginate >200)
#Physical Exam (when to perform brain death)
##must have no mention, no motor or sensory response. (no movement or hemodynamic response(increased tachycardia) to noxious stimulation).
# Test:
# Test:
##Connect pulse ox, disconnect ventilator, place nasal cannula in ET (at carina), and place on 100% O2, observe for resp movements, draw [[ABG]] @ 8 min.
##check baseline ABG (ensure PCO2 <40mmHg to maximate target PCO2 rise)
##Pos test = 20 increase over baseline (typically 60) ensure to blow down CO2 to ~40 to enable 20mmHg rise.
##Connect pulse ox, disconnect ventilator, place nasal cannula in ET (at carina), and place on 100% O2 @ 6LPM.
##reconnect ventilator if SBP <90 or sig O2 desat (can draw [[ABG]] @ that time, with same criteria as above).
##Physician able to declare brain death (typically neurology/neurosurgery) will  observe for resp movements
##Draw [[ABG]] @ 8 min. Observe for PCO2 rise >20mmHg over 8 minutes with no respiratory movement -->positive apnea test (supports brain death)
###Pos test = 20 increase over baseline (typically 60) ensure to blow down CO2 to ~40 to enable 20mmHg rise. Typical rise is 3mmHg per minute
#Considerations
##Abort the test (reconnect ventilator) if SBP <90 or sig O2 desat (can draw [[ABG]] @ that time, with same criteria as above).
##Must perform 2 exams 6 hours apart in addition to apnea test.
##Must perform 2 exams 6 hours apart in addition to apnea test.


Revision as of 19:44, 23 December 2013

Criteria

  1. Known proximate cause of condition
  2. Exclusion of complicating medical conditions (severe electrolyte, acidbase, or endocrine disturbance)
  3. No drug intoxication/poisoning
  4. Core temp >32C (90F)
  5. Cerebral unresponsiveness
  6. Absence of brain stem relexes (see below)
  7. Apneic (see below)
  8. Irreversible condition (+/- repeat exam in 6hrs)

Brain Stem Reflexes

  1. Pupils
    1. no response to light (fixed and mid-dialated)
  2. Ocular movement
    1. no oculocephalic reflex (+Doll's Eyes)
    2. no vestibulocochlear (deviation of eyes to irrigation w/ 50mL cold water to ears - allow 1 min after and 5 min b/t)
  3. Facial motor response/sensation
    1. jaw reflex (grimacing to deep facial pressure)
    2. corneal reflex (touch eye w/ swab)
  4. Paryngeal/tracheal
    1. gag (tounge blade)

Apnea Testing

  1. Prerequisites:
    1. Clinical Criteria
    2. Core temp >32 C (actual temp value > 32 varies by institution) with corrected electrolytes. > 36.5C is preferred.
    3. SBP >90
    4. Nl PCO2 (>40)
    5. Nl PO2 (preoxiginate >200)
  2. Test:
    1. check baseline ABG (ensure PCO2 <40mmHg to maximate target PCO2 rise)
    2. Connect pulse ox, disconnect ventilator, place nasal cannula in ET (at carina), and place on 100% O2 @ 6LPM.
    3. Physician able to declare brain death (typically neurology/neurosurgery) will observe for resp movements
    4. Draw ABG @ 8 min. Observe for PCO2 rise >20mmHg over 8 minutes with no respiratory movement -->positive apnea test (supports brain death)
      1. Pos test = 20 increase over baseline (typically 60) ensure to blow down CO2 to ~40 to enable 20mmHg rise. Typical rise is 3mmHg per minute
  3. Considerations
    1. Abort the test (reconnect ventilator) if SBP <90 or sig O2 desat (can draw ABG @ that time, with same criteria as above).
    2. Must perform 2 exams 6 hours apart in addition to apnea test.

One-Legacy 800-338-6112

See Also

Source

2/8/07 DONALDSON (adapted from One-Legacy)

Retrieved from "https://www.wikem.org/w/index.php?title=Brain_death&oldid=15400"