†
Confirmatory testing can include: electroencephalography, transcranial Doppler flow study, somatosensory
evoked potentials, brain scan with technetium-99m, or cerebral angiography.
From References 30–32.
Disorders of Consciousness
811
Instructions:
Check (
✔
)
The patient can be declared legally dead if Steps 1–4
Item if
are confirmed, or there is a positive confirmatory test.
Confirmed
Step 1: Prerequisite to Exam:
All of the following conditions should be corrected before
❏
beginning the brain death evaluation.
• Hypotension (mean arterial pressure
<
65 mm Hg)
• Hypothermia (core temp
<
32°C or
<
90°F)
• Hypothyroidism
• Hypoglycemia
• Effects of CNS depressant drugs
Step 2: Establish the Cause of Coma:
The cause of coma is known, and is sufficient to account
❏
for irreversible brain death.
Step 3: Absence of Brain and Brainstem Function:
This step involves two sequential exams. There is no
First Second
agreement about the length of time required between
Exam Exam
exams, but 6 hours is a popular choice.
A. The patient is comatose (unaware and unresponsive).
❏ ❏
B. The following brainstem reflexes are absent:
❏ ❏
• Absent pupillary response to bright light
• Absent corneal reflex
• Absent gag and cough reflexes
• Absent oculocephalic reflex
• Absent deviation of eyes with cold water stimulation
of the tympanic membrane
Step 4: Absence of Spontaneous Breathing Efforts:
There are no spontaneous breathing efforts when the
❏
arterial PCO
2
is 20 mm Hg above the patient’s baseline
level (positive apnea test).
Step 5: Consider Confirmatory Tests:
†
Confirmatory tests may be necessary when Steps 1–4 cannot be
completed or unequivocally interpreted.
Table 44.5
Checklist for Brain Death Determination in Adults
