American acadamy wait for 1 min and 5 min in b/w 2 ears
Ice water to the right ear inhibits the right vestibular system and allows the normal left vestibular system to drive the eyes to the right (NORMAL RESPONSE)
1 – positive fluid balance for last 6 hours 2- pao2 &gt;200 3- paco2&gt;40 4-temp 97 Catastrophe can be-sah ,ich, severe head injury,fulminant liver failure
American acadamy 8 min @ 6 lit/min
If bp becomes &lt;90,oxygen desaturation occurs,arrythmias occur connect vetilator take abg if paco2 &gt;60,20 mm increase in paco2 from baseline result positive if paco2&lt;60,paco2 rise &lt;20 result indeterminate
EEG-2micro volt/mm or more
Sensitivity is 90%
Brain dead and organ
Dr Ajeet singh
Altered states of
Sleep-normal state of unconsciousness with
prompt reversiblity on thershold sensory stimulus
and maintin wakefulness following recovery.
required and wakefulness cannot be maintained
unless the stimulation continued
Stuporous-arousable only with vigorous noxious
stimuli,while awake cant demonstrate normal
content of consciousness
Coma- A state of unconsciousness from which the
patient cannot be aroused even with stimulation
such as pressure on the supraorbital nerve,
temporomandibular angle of the mandible,
sternum, or nailbed
Locked-in state-state of paralysis without loss of
consciousness.patient completely paralysed
except for muslces subserved by midbrain
structure[e.g.vertical eye movemnt and blinking]
Persistent vegetative state-
-also known as cerebral death.
-normal sleep-wake cycles.
-no response to environmental stimuli.
-diffuse brain injury with preservation of brain stem
Refers to determination of physical death by
brain based,rather than cardio-pulmonary based
Its is defined as a irreversible destruction of the
brain,with the resulting total absence of all
cortical and brainstem functions,although spinal
cord refleves may remain
It should not be confused with severe but
incomplete brain damage or with vegetative state
in which some function of vital brain centers still
remains,and decisions regarding on going life
support clearly depend on the wishes of the
patient or his/her proxy.
Brain death should be suspected in any patient
rendered deeply comatose and apneic from a
profound or diffuse brain insult
Pathogenesis of brain death- Direct cellular injury
potentiated by a vicious cycle of failure of blood
flow, hypoxia, cerebral acidosis and endothelial
swelling to brain edema,aseptic necrosis and
herniation of the brain.
When the lower brain herniates through the skull
onto the brainstem and pons, cutting off the
blood supply to the brain.
Prerequisites for testing of brain death
- Clinical or neuro-imaging evidence of acute
catastrophe leading to a diagnosisdiagnosis of brain
-No severe electrolyte , acid base, endocrine
-no drug intoxication
- core temperature>90 degree Farenheit
Brain Death Diagnosis
made by the separate examination of 2 doctors:
1. One of the doctors must be a specialist recognized by
the appropriate College as having demonstrated skill
and knowledge in the performance of brain death
certification. This should usually be an intensivist,
critical care physician, neurologist or neurosurgeon .
2. The other medical practitioner should preferably be of
the same qualification as described in 1. but should be at
least 6 years after registration & possess the skill and
knowledge in the performance of brain death
Criteria for CNS Determination of Death
Absence of cortical function
Absence of brainstem function
2 examinations with interval according to
Known etiology and or reversible causes ruled out
Must have an absence of
Shock or significant hemodynamic instability
Significant levels of sedatives
Severe metabolic distrubance
Absence of cortical functions-
No spontaneous movement, eye opening, or
movement or response after auditory, verbal, or
Cerebral motor response to pain
Supraorbital ridge, the nail beds, trapezius
Motor responses may occur spontaneously
during apnea testing (spinal reflexes)
Spinal arcs are intact!
7)No integrated motor response to pain
Midsize (4-6 mm), but may be totally dilated
Absent pupillary light reflex
Although drugs can influence pupillary size, the
light reflex remains intact only in the absence of
IV atropine does not markedly affect response
Paralytics do not affect pupillary size
Topical administration of drugs and eye trauma
may influence pupillary size and reactivity
Pupils fixed and unresponsive to light
•Pre-existing ocular anatomic abnormalities may also
confound pupillary assessment in brain death
Corneal reflexes are absent in brain death
Corneal reflexes - tested by using a cotton-
There is no blink response to direct corneal stimulation.
Gag and Cough reflex-
Both gag and cough reflexes are absent in patients
with brain death
Gag reflex can be evaluated by stimulating the
posterior pharynx with a tongue blade.
Cough reflex can be tested by using ETT
suctioning, past end of ETT
Rapidly turn the head 90° on both sides
Normal response = deviation of the eyes to the
opposite side of head turning
Brain death = oculocephalic reflexes are absent
(no Doll’s eyes) = no eye movement in response
to head movement
No eye movements within 3 mints after irrigating
each tympanic membrane (if intact) sequentially
with 50 ml ice water for 30 to 45 seconds while the
head of the supine patient is elevated 30 degrees
Retained vestibulocular reflex
Eyes do not deviate away cold water
instilled into an auditory canal.
Cold calorics interpretation
Nystagmus; both eyes slow toward cold, fast to midline
Coma with intact brainstem
Both eyes tonically deviate away cold water
No eye movement
Brainstem injury / death
Movement only of eye on side of stimulus
Suggests brainstem structural lesion
-Core temp 36.5°C
- SBP >90 mm Hg
-No electrolyte imbalance
-Arterial pH 7.35-7.45 and pCO2 35-45 mm Hg
-Preoxygenation with 100% FiO2 for 10 to 15 mints
Give 100% O2 at 8-10 Lpm (through a catheter) at
the level of carina immediately after
disconnecting the ventilator.
Observe closely for respiratory movements (abd
and chest excursions)
Measure pO2, pCO2 and pH after apprx. 3-5 mints
and reconnect the ventilator
If respiratory movements are absent and final
-pCO2 increases from 40 up to 60 mm Hg or 20
mm Hg from pretest baseline then, Apnea has
been demonstrated, supporting the diagnosis of
brain death criteria.
If the above criteria are not met and apnea test is
negative-Confirmatory tests are required
Pitfalls in clinical brain death
Hypotension, shock-Fluid resuscitation, pressor
Hypothermia-Warmed fluids, ventilatory warmer
Intoxication or drug overdose-Serum drug levels
and toxicology screens, or increase waiting time
between brain-death examinations
Damage to the base of the pons, typically from a
basilar artery embolism, can result in the
development of the so-called locked-in syndrome,
where the patient loses all voluntary movements
with the exception of blinking and vertical eye
GBS can involve all peripheral and cranial nerves
and mimic brain death.
Neuromuscular and sedative drugs, which can
interfere with elicitation of motor responses-
Discontinue muscle relaxants and mood- or
consciousness-altering medications, increase
waiting time between brain-death examinations
Pupillary fixation, which may be caused by
anticholinergic drugs, neuromuscular blocking
agents, or preexisting disease
Oculovestibular reflexes diminished after prior use
of ototoxic drugs (e.g., aminoglycosides, loop
diuretics, vancomycin) or agents with suppressive
side effects on the vestibular system (e.g., TCADs,
anticonvulsants and barbiturates) or due to
preexisting disease or any foreign body in EAC[e.g
Obtain careful medication history and patient
Doll's eyes examination should not be performed
if the cervical spine is unstable.
Chronic obstructive pulmonary disease or sleep
apnea may result in elevated baseline CO2
retention, confounding the apnea examination
Certain spinal reflexes including spontaneous
movements of the torso, arms, or toes should be
ignored if the clinical brain stem examination is
consistent with brain death or confirmatory
examinations are positive.
Used as a supportive in those patients in whom
specific components of clinical testing cannot be
reliably performed or evaluated.
Confirmatory test findings are listed in the order
of the most sensitive test first –
1)Conventional angiography. No intracerebral
filling at the level of the carotid bifurcation or
circle of Willis .
2) Electroencephalography- Absence of any cerebral
activity during at least 30 min of recording
3) Transcranial Doppler ultrasound -should show absent
diastolic flow with small early systolic peaks.
4) SPECT using Technetium brain scan- No uptake of
isotope in the brain parenchyma
5)Somatosensory evoked potentials-Bilateral absence of
response with median nerve stimulation confirms brain
Blood flow is absent in the cranial vault
when examined by cerebral scintigraphy
(shown) or angiography.
SPECT using Technetium brain scan-
Cerebral perfusion scan
TCD and Brain death
2 examinations at an interval of 30 minutes if shows
cerebral circulatory arrest
Small systolic peaks in early systole without
diastolic flow in any of MCA,ICA and any artery
of anterior and posterior circulation.
Intracranial examination should be confirmed
with extracranial recording
Lack of flow in basal arteries can be false
TCD and Brain Death
TCD can be a confirmatory tool for diagnosing brain
death. The validity of TCD diagnosed brain death
depends on the time lapse between brain death and
the performance of TCD. TCD of both the basilar
artery and the MCAs showed significant consistency
in brain death diagnosis.
The specificity of TCD is close to 100%.
The sensitivity of TCD is 91- 100% .
Kids over 1 year old
Absence of all brain and brainstem function
Comatose: no purposeful response to any stimulus
Brainstem function is absent when:
Pupils are mid-position and do not react to light
Eyes does not blink when touched (corneal reflex)
Eyes do not rotate in the socket when the head is moved from
side to side (oculocephalic reflex).
Eyes do not move when ice water is placed in the ear canal
Child does not cough or gag when a suction tube is placed deep
into the breathing tube
Child does not breathe when taken off the ventilator
Repeat in ~6 hours
Children under 1 year
Necessary to repeat the clinical examination after
an ‘appropriate’ observation period has passed
Age 7 days to 2 months
Two examinations 48 hours apart and one EEG
Age 2 months-1 year
Two examinations 24 hours apart and one EEG or
Confirmatory EEG unless it is determined that
there is no blood flow to the brain
Organ donation has been one of the greatest
advances of modern science that has resulted in many
patients getting a renewed lease of life.
It means that a person pledges during his lifetime
that after death, organs from his/her body can be
used for transplantation to help terminally ill patients
and giving them a new lease of life.
Types of organ donation-
1)living related- donor remains alive and donates a
renewable tissue, cell, or fluid (e.g. blood, skin), or
donates an organ or part of an organ ((primarily
single kidney donation, partial donation of liver, small
2)living non related(brain death and cadeveric
donor)-In brain- dead organs are kept viable by
ventilators or other mechanical mechanisms until
they can be excised for transplantation.
Commonly donated organs from brain death are –
kidney ,cornea ,heart, lung, liver, pancreas, skin.
Cadeveric donar-Tissues may be recovered from
donors up to 24 hours past the cessation of heartbeat.
Cadeveric donar are major source of organs and
Almost everywhere organ donation is voluntary-
tTwo voluntary systems include –
1.Opt In - Where the donor gives consent
2.Opt Out - Where anyone who has not refused is
considered as a donor
In India we have the Opt in system, while many
western countries practice the opt out system
Worldwide, the demand for organs is growing, as the
supply of organs and tissues for transplantation has
not kept pace with demand.
In the UK only approximately 900 individuals
become organ donors each year, while over 6000
people are waiting for suitable organs.
The reasons for the shortage of organ donation are-
2) Superstitious belief
3) Fear, ignorance and misunderstanding
4) Legal aspects
5) Media reports on scandals involving organ
To attempt to overcome the uncontrollable trade in
organs the Indian parliament implement
transplantation of human organ act in 1994.
The essence of this legislation was threefold:
1. To accept brain death as also a definition of death.
2. To stop commercial dealing in organs
3. To define the first relative (father, mother, brother,
sister, son, daughter and wife) who could donate
organs without permission from the government
Organ transplant law does not allow exchange of
money between the donor and the recipient.
Unrelated donor has to file an affidavit in the court of
a magistrate stating that the organ is being donated
out of affection.
If it is found that the money has been exchanged in
the process then both the recipient as well as the
donor are considered as prime offenders under the
Current status of organ donation act-
It is proposed to amend the THO Act by changing its
name from ‘Transplantation of Human Organs Act’ to
‘Transplantation of Human Organs & Tissues Act’
Law will broaden the definition of ‘near relative’ to
include grandparents, grandchildren, uncles and
aunts. Also, not-so-close relatives who have stayed
with the patient can donate organs, provided there is
no commercial dealing.
Also recommended that every hospital should make
it mandatory for the ICU/ Treating Medical Staff to
request relatives of brain dead patients for organ
To ask each patient on or before admission to a
hospital as soon as thereafter as to whether the
person has pledged a donation of organ or tissue.
To prohibit grant of permission by the authorization
committee for organ transplantation where the
recipient is a foreign national and the donor is an
“No cells, tissues or organs should be removed from
the body of a living minor for the purpose of
transplantation other than narrow exceptions allowed
under national law.(eg.kidney transplantation betw
To have a post of ‘transplant coordinator’ in ICU’s of
hospitals and centers with transplant activity.
Enhancement of Penalties-the term “five years” years
shall be substituted by the term “ten years” and the
term “ten thousand rupees” shall be substituted by
term“five lakh rupees”
Organ donation algorithm-
Hospital Organ Donation Registry
(HODR)coordinates the process of cadaver organ
During lifetime, a person can pledge for organ
donation by filling up a donor form in the presence of
two witnesses, one of who shall be a near relative and
send the same to HODR
The organ donor form could be obtained from HODR
either personally or through mail
After receiving the filled in form, HODR provides the
donor with an organ donor card bearing registration
number on it.
It is suggested to keep the donor card in your pocket
and share your decision with your near and dear ones.
If a person expires without registration, the family
members can donate his/her organs. For this they
need to sign a consent form, which is provided at that
Once, the relatives give a written consent, organs are
harvested within a few hours.
The family of the donor does not face any difficulty or
extra burden upon them.
The transplant coordination team carries out the
entire process till the relatives receive the body of the
Contraindications to donation
Hepatitis B or Hepatitis C may be acceptable for
IV drug abuse or practicing homosexual
Untreated bacterial, fungal or viral infection
(treated infection may be considered)
Malignancies other than primary brain tumours
and nonmelanoma skin cancers
ORGAN RETRIEVAL BANKING ORGANISATION (ORBO)
ALL INDIA INSTITUTE OF MEDICAL SCIENCES
ORGAN DONOR FORM
Date Regd. No.
I, ……………………………………………………………………son / daughter / wife of
………………………………………………………………………...in the hope that I may
help other hereby make this anatomical gift, if medically acceptable, to take
effect upon my brain death. I hereby with to donate the following organs.
Hearts, Lungs, Kidneys, Liver, Corneas &
My blood group is …………………………………
Special wishes, if any
Signed by the donor in the presence of two witnesses:
Signature of donor with date Date of birth of donor
Address of the donor