Brain Death Anatomy and Physiology Joel S. Cohen,

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>Brain Death Anatomy and Physiology  Joel S. Cohen, M.D.    Brain Death Anatomy and Physiology Joel S. Cohen, M.D. Associate Professor of Clinical Neurology Albert Einstein College of Medicine

>Historical Perspective     Prior to the advent of mechanical respiration, death Historical Perspective Prior to the advent of mechanical respiration, death was defined as the cessation of circulation and breathing

>Historical Perspective 1959 Coma de’passe’ Mollaret and Goulon  1968 Irreversible Coma/Brain Death Harvard Historical Perspective 1959 Coma de’passe’ Mollaret and Goulon 1968 Irreversible Coma/Brain Death Harvard Medical School Ad Hoc Committee 1981 Uniform Determination of Death Act - President’s Commission for the Study of Ethical Problems in Medicine 1994 American Academy of Neurology Guidelines for the determination of Brain Death 2005 NYS Guidelines for Determining Brain Death

>Brain Death Current Consensus Absent Cerebral Function   Absent Brainstem Function  Brain Death Current Consensus Absent Cerebral Function Absent Brainstem Function Apnea

>Normal Brain Anatomy Normal Brain Anatomy

>Normal Brain Anatomy Cerebral Cortex Brain Stem Reticular Activating System Normal Brain Anatomy Cerebral Cortex Brain Stem Reticular Activating System

>Cerebral Cortex Cognition Voluntary Movement Sensation Cerebral Cortex Cognition Voluntary Movement Sensation

>Brain Stem Brain Stem

>Brain Stem  Midbrain Cranial Nerve III  pupillary function  eye movement Brain Stem Midbrain Cranial Nerve III pupillary function eye movement

>Brain Stem Pons    Cranial Nerves IV, V, VI  conjugate eye Brain Stem Pons Cranial Nerves IV, V, VI conjugate eye movement corneal reflex

>Brain Stem  Medulla     Cranial Nerves IX, X  Brain Stem Medulla Cranial Nerves IX, X Pharyngeal (Gag) Reflex Tracheal (Cough) Reflex Respiration

>Reticular Activating System  Receives multiple sensory inputs  Mediates wakefulness Reticular Activating System Receives multiple sensory inputs Mediates wakefulness

>Causes of Brain Death Normal Cerebral Anoxia Causes of Brain Death Normal Cerebral Anoxia

>Causes of Brain Death Normal Cerebral Hemorrhage Causes of Brain Death Normal Cerebral Hemorrhage

>Causes of Brain Death Normal Subarachnoid Hemorrhage Causes of Brain Death Normal Subarachnoid Hemorrhage

>Causes of Brain Death Normal Trauma Causes of Brain Death Normal Trauma

>Causes of Brain Death Normal Meningitis Causes of Brain Death Normal Meningitis

>Mechanism of Cerebral Death Increased Intracranial   Pressure ICP>MAP is incompatible with life Mechanism of Cerebral Death Increased Intracranial Pressure ICP>MAP is incompatible with life

>Conditions Distinct From Brain Death Persistent Vegetative State  Locked-in Syndrome  Minimally Responsive Conditions Distinct From Brain Death Persistent Vegetative State Locked-in Syndrome Minimally Responsive State

>Persistent Vegetative State Normal Sleep-Wake Cycles   No Response to Environmental Stimuli Persistent Vegetative State Normal Sleep-Wake Cycles No Response to Environmental Stimuli Diffuse Brain Injury with Preservation of Brain Stem Function

>Locked-in Syndrome Ventral Pontine Infarct  Complete Paralysis   Preserved Consciousness  Locked-in Syndrome Ventral Pontine Infarct Complete Paralysis Preserved Consciousness Preserved Eye Movement

>Minimally Responsive State Diffuse or Multi-Focal Brain Injury  Preserved Brain Stem Function Minimally Responsive State Diffuse or Multi-Focal Brain Injury Preserved Brain Stem Function Variable Interaction with Environmental Stimuli Static Encephalopathy

>Brain Death Neurological Examination Clinical Prerequisites:  Known Irreversible Cause  Exclusion of Potentially Brain Death Neurological Examination Clinical Prerequisites: Known Irreversible Cause Exclusion of Potentially Reversible Conditions Drug Intoxication or Poisoning Electrolyte or Acid-Base Imbalance Endocrine Disturbances Core Body temperature > 32° C

>Brain Death Neurological Examination Coma  Absent Brain Stem Reflexes  Apnea Brain Death Neurological Examination Coma Absent Brain Stem Reflexes Apnea

>Coma No Response to Noxious Stimuli  Nail Bed Pressure  Sternal Rub Coma No Response to Noxious Stimuli Nail Bed Pressure Sternal Rub Supra-Orbital Ridge Pressure

>Absence of Brain Stem Reflexes Pupillary Reflex  Eye Movements  Facial Sensation and Absence of Brain Stem Reflexes Pupillary Reflex Eye Movements Facial Sensation and Motor Response Pharyngeal (Gag) Reflex Tracheal (Cough) Reflex

>Pupillary Reflex Pupils dilated with no constriction to bright light Pupillary Reflex Pupils dilated with no constriction to bright light

>Eye Movements  Occulo-Cephalic Response “Doll’s Eyes Maneuver” Eye Movements Occulo-Cephalic Response “Doll’s Eyes Maneuver”

>Eye Movements Oculo-Vestibular Response “Cold Caloric Testing” Eye Movements Oculo-Vestibular Response “Cold Caloric Testing”

>Facial Sensation and Motor Response Corneal Reflex      Jaw Reflex Facial Sensation and Motor Response Corneal Reflex Jaw Reflex Grimace to Supraorbital or Temporo-Mandibular Pressure

>Apnea Testing Prerequisites  Core Body Temperature > 32° C  Systolic Blood Pressure Apnea Testing Prerequisites Core Body Temperature > 32° C Systolic Blood Pressure ≥ 90 mm Hg Normal Electrolytes Normal PCO2

>Apnea Testing 1. Pre-Oxygenation 100% Oxygen via Tracheal Cannula  PO2 = 200 mm Apnea Testing 1. Pre-Oxygenation 100% Oxygen via Tracheal Cannula PO2 = 200 mm Hg 2. Monitor PCO2 and PO2 with pulse oximetry 3. Disconnect Ventilator 4. Observe for Respiratory Movement until PCO2 = 60 mm Hg 5. Discontinue Testing if BP < 90, PO2 saturation decreases, or cardiac dysrhythmia observed

>Confounding Clinical Conditions Facial Trauma  Pupillary Abnormalities  CNS Sedatives or Neuromuscular Blockers Confounding Clinical Conditions Facial Trauma Pupillary Abnormalities CNS Sedatives or Neuromuscular Blockers Hepatic Failure Pulmonary Disease

>Observations Compatible with Brain Death Sweating, Blushing  Deep Tendon Reflexes  Spontaneous Spinal Observations Compatible with Brain Death Sweating, Blushing Deep Tendon Reflexes Spontaneous Spinal Reflexes- Triple Flexion Babinski Sign

>Confirmatory Testing    Recommended when the proximate cause of coma is not Confirmatory Testing Recommended when the proximate cause of coma is not known or when confounding clinical conditions limit the clinical examination

>Confirmatory Testing EEG Normal Electrocerebral Silence Confirmatory Testing EEG Normal Electrocerebral Silence

>Confirmatory Testing Cerebral Angiography Normal No Intracranial Flow Confirmatory Testing Cerebral Angiography Normal No Intracranial Flow

>Confirmatory Testing Technetium-99 Isotope Brain Scan Confirmatory Testing Technetium-99 Isotope Brain Scan

>Confirmatory Testing MR- Angiography Confirmatory Testing MR- Angiography

>Confirmatory Testing Transcranial Ultrasonography Confirmatory Testing Transcranial Ultrasonography

>Confirmatory Testing Somatosensory Evoked Potentials Confirmatory Testing Somatosensory Evoked Potentials

>Concern for man and his fate must always form the chief interest of all Concern for man and his fate must always form the chief interest of all technical endeavors. Never forget this in the midst of your diagrams and equations. Albert Einstein




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