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Chapter 16. Brain Death

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A 24-year-old woman suffers a pulseless electrical activity (PEA) arrest following a prolonged asthma attack. Bystanders perform cardiopulmonary resuscitation and call 911; emergency medical services (EMS) arrive at the scene within 15 minutes. Return of spontaneous circulation is achieved after 45 minutes. She is taken to a nearby hospital, and on initial evaluation, she is hemodynamically stable, but her neurologic exam is concerning for brain death. Her condition remains unchanged 48 hours after completing targeted temperature management (TTM). Following further conversations with her family, a clinical examination is repeated.

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Which of the following parameters is a prerequisite for a brain death evaluation according to the 2010 American Academy of Neurology (AAN) criteria?

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A. Underlying structural etiology confirmed by history and visualized on neuroimaging

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B. Presence of severe electrolyte abnormalities

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C. Systolic blood pressure (SBP) >90 mm Hg in the absence of any vasopressors

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D. Required hypothermia for 24 hours, if there was a cardiac arrest

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E. Family consent to proceed with the exam, or clear and unequivocal documentation of organ donation status (such as a driver’s license or other legal paperwork)

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A. Prerequisites for performing a brain death evaluation are listed in Table 16-1. Normotension is also a prerequisite; however, the SBP should be >100 mm Hg, and vasopressors may be used to achieve this goal. Family consent or documentation of organ donation status is not mandatory prior to a brain death evaluation in most states and is not listed as a prerequisite according to the 2010 AAN criteria. In the setting of a cardiac arrest, there is no requirement for prior therapeutic hypothermia to make the diagnosis of brain death because not all patients qualify for cooling.

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Table 16-1. Prerequisites for Performing a Brain Death Evaluation (All Criteria must be Fulfilled)
1.1. Coma with a clearly established irreversible and proximate cause (determined by history, exam, neuroimaging)
1.2. Exclude presence of a central nervous system depressant drug
1.3. Normothermia or near-normal core body temperature (>36°C)
1.4. No recent administration or residual presence of paralytic agents (can check train of 4 twitches)
1.5. Absence of a severe electrolyte, acid-base, or endocrine abnormality
1.6. Systolic blood pressure ≥100 mm Hg (vasopressors or vasopressin may be used)
1.7. No spontaneous respirations noted on the ventilator

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A 24-year-old woman suffers a pulseless electrical activity (PEA) arrest following a prolonged asthma attack. Bystanders perform cardiopulmonary resuscitation and call 911; emergency medical services (EMS) arrive at the scene within 15 minutes. Return of spontaneous circulation is achieved after 45 minutes. She is taken to ...

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