Assess the patient 4 days post head injury Is he brain dead Likely candidate for donation Mx of organ donor

Case severe head injury/SAH/stroke/Hypoxic injury Ask age <65 suitable Monitors T>35 Stable haemodyn No infusions/or infusion for BP control off sedations temp ask electrolytes e/o renal hepatic failure ask TOF Exam Brains stem Look for CI for apnea test-hemodynamic instability/unclear Cx spine Inability assess brain stem reflexes due to multiple confounders Ask e/o seizures

Do apnea testing-expecting----no respiratory response toPOC2 >60 or >20 baseline Baseline ABG-disconnect ventilator-

The procedure for apnea testing is given in Table 2. To avoid the cardiac dysrhythmias and systemic hypotension that may occur during the test, clinicians should follow the recommendations given in Table 3. The results of apnea tests are interpreted as (1) positive, (2) negative, (3) occurrence of cardiovascular or pulmonary instability, and (4) inconclusive (Table 4).

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Ancillary tests the cause of apparent brain death is not obvious in the presence of significant sedative drugs Clinical Observation Intervals metabolic disturbance renal/liver failure Ine.g. clinical determination of brain death, persistent observation further confirm irreversibility of the patient s condition. A repeatnerves clinical evaluation of cardin facial trauma preventing adequate examination of all cranial findings in brain death is recommended. Most experts recommend an arbitr in cardio-respiratory failure and instability when the apnoea test interval of 6 hours between initial and repeat observations for clinical determ would be considered to be too dangerous to perform of brain death in adults; however, a firm recommendation based on scientifi 13,21 cervical cord or vertebral injury literature cannot be given. All clinical tests of cardinal findings are equ essential in declaring brain death. 4 vessel angiography vertebral and carotid arteries are filled from the arch of the aorta. Blood flow Confirmatory Tests for Determination should not be demonstrated above the level of theof Brain Death Although confirmatory tests are not mandatory in most situations, additiona carotid bifurcation (Table 5) may be necessary for declaring brain death in patients in whom th Radionuclide scanning cerebral perfusion scan: of specific components of clinical testing cannot be reliably evaluated. 13 Cl experience with confirmatory tests other than conventional reliably demonstrates the absence of brain perfusion angiography,

lectroencephalography, and transcranial Doppler sonography is limited. Res involving use of confirmatory tests for determination of brain death is const lack of blinded evaluation, absence of interobserver reliability data, and spa of control groups.

Conventional Cerebral Angiography Selective 4-vessel angiography may be performed in the neuroradiology dep In patients with brain death, intracerebral filling is absent at the level of the

Maintenance of extra-cerebral physiologic stability aim to maintain organ perfusion and prevention and treatment of physiological derangement caused by brain death. either Supportive and Specific measures 1. SUPPORTIVE measures to maintain normal physiologic parameters Circulatory management -adequate organ perfusion pressure eg. MAP >70, HR<100, CVP 8 Ventilatory management - good oxygenation, normocarbia , minimize circulatory depression,if possible keep good lung function for future lung donation Metabolic management - correct electrolytes, glucose abn , keep core temp >35-36.5C 2.SPECIFIC measures to treat the complications of brain death Cardiovascular complications : Autonomic storm -consider BBlocker Hypotension -volume loading, inotropes if unresponsive consider steroids Arrhythmias - correct underlying cause eg. electrolytes abn, hypotension Diabetes Insipidus (high plasma osmol, low urine Na/osmol, high UO) IV D5W, IV Desmopressin Hypothermia - blankets, warm IV fluids, humidified inspired air Hypothyroidism - either real hypothyroidism or sick euthyroid syndrome Hyperglycemia sec to osmotic diuresis - fluids and electrolytes correction, insulin IV Avoid and treat atelectasis and excessive fluids-potential lung donors

Brain Death 10/4/11 Examinations Book GENERAL APPROACH Diagnosis

Exclusion of treatable causes Preconditions Responsiveness Brainstem reflexes Apnoea Imaging INTRODUCTION CUBICLE INFUSIONS - sedation cannot be declared brain dead - nimodipine (SAH) VENTILATOR - no spontaneous breaths - coughing on suctioning MONITOR - abnormally elevated ICP - bradycardia - temperature (hypothermia) EQUIPMENT parenchymal ICP monitor EVD with blood stained CSF evidence of recent cooling (refractory ICP or out-of-hospital cardiac arrest) copious urinary drainage (DI)

QUESTION SPECIFIC EXAMINATION Equipment required -> torch - >cotton bud -> tongue depressor -> otoscope -> PNS (train of four) -> 50mL syringe with iced water -> ETCO2 -> Mapleson C circuit (allows PEEP and to observe bag for any effort) -> laryngoscope (to test gag with direct vision) Neurological

-> GCS -> response to pain (supraorbital, TMJ and all four limbs) -> pupils -> corneals -> otoscopy and vestibule-ocular reflex -> gag under laryngoscopic vision -> cough with tracheal suctioning -> apnoea (attach patient to bag mask/Mapelson C circuit/oxygen catheter down ETT and wait until PaCO2 > 60mmHg or has increased to 20mmHg higher than baseline) Hands -> head -> chest -> abdo -> feet -> back -> cardiovascular -> respiratory -> abdominal irreversible cause of coma been established patients temperature how long have they had this neurological state? last sedation, analgesia or paralysis metabolic and endocrine state toxin/poisoning ruled out urine output (DI) second examination by a suitably trained doctor

RELEVANT INVESTIGATIONS - CT head OPENING STATEMENT = Yes Unable to tell Not but prognosis poor - present reasons why.