Date
Time
The answer to the following must be Yes:
|
Cause known
(accounts for the severity of coma?) |
Y / N |
|
Neuro-imaging evidence of acute CNS
catastrophe that is compatible with
the clinical diagnosis of brain death |
Y / N |
|
| Toxic causes absent |
Y / N |
|
| Metabolic causes absent |
Y / N |
Y / N |
Adequate core temperature
(i.e. temperature > 35oC or 95oF) |
Y / N |
Y / N |
|
| The answer to the following must be No: |
|
| Alcohol consumed in last 6 hrs |
Y / N |
|
|
| Nohistory of recent treatment with sedatives, narcotics or musclerelaxants. The following have been given in the last 6 hours:) |
|
| Pancuronium |
Y / N |
Y / N |
| Midazolam / Propofol |
Y / N |
Y / N |
| Morphine / Fentanyl |
Y / N |
Y / N |
| Phenobarbitone used as anticonvulsant |
Y / N |
Y / N |
B. Absent brainstem reflexes
|
| Pupils non-reactive |
Y / N |
Y / N |
| Absent doll's eye movement |
Y / N |
Y / N |
| Cold caloric test: |
| Tympanic membrane found intact |
Y / N |
Y / N |
| Ocular movement absent |
Y / N |
Y / N |
Absent corneal reflex
(Use swab stick) |
Y / N |
Y / N |
| Absent gag reflex |
Y / N |
Y / N |
Absent cough reflex
(to suction catheter tip or ET tube movement) |
Y / N |
Y / N |
C. Apnoea test
|
| Pre-requisites at the time of testing: |
| - Core temperature > 35oC or 95oF |
Y / N |
Y / N |
| - Systolic BP more than or equal to 90 mmHg. |
Y / N |
Y / N |
| - ositive fluid balance in the past P Y 6 hours |
Y / N |
Y / N |
Apnoea test methodology: It is assumed that the patient is being ventilated at a pCO2 between 30-35 mmHg.
- Decrease respiratory rate by 2, increase FiO2 to 1.0
- Send ABG to confirm pCO2 around 40-45 mmHg (optional)
- Accurately measure length of oxygen catheter to reach 1cm beyond thetip of the ET tube, insert up to the mark after disconnectingventilator; set oxygen flow at 10 L/min
- Observe carefully for respiratory movements with hand on patient's chest
- Send ABG after at least 6 minutes (longer if patient stable) and reconnect the ventilator.
Abort the test if
- systolic BP drops below 90 mm Hg, or
- SpO2 drops below 91%, or
- significant cardiac arrhythmias develop
If the test has to be aborted repeat after 3 hours.
The apnoea test is positiveif respiratory movements are absent, and arterial pCO2 is more than or equal to 60 mm Hg or the rise is by 20 mm above the baseline(i.e. 2 mm rise per minute)
A single incident of shrugging of shoulders or arching of back does not represent respiratory movements
The apnoea test is negative if respiratory movements are present. (watch for repetitive sustained movements)
The apnoea test is indeterminate if respiratory movements are absent, and arterial pCO2 is less than 55 mm Hg.
If indeterminate and strong clinical grounds to suspect apnea are present, correct parameters and repeat the test.
Apnoea test I
pCO2 after apnoea: mmHg
Result: Positive / indeterminate / negative
Apnoea test II
pCO2 after apnoea: mmHg
Result: Positive / indeterminate / negative
|
DIAGNOSIS OF BRAIN DEATH
|
| Brain death is present if yes to all questions below on both assessments: |
| A. |
All criteria for irreversible coma present |
Yes / No |
| B. |
All brainstem reflexes absent on neurological examination |
Yes / No |
| C. |
Apnoea test is positive |
Yes / No |
Brain death is absent if the answer to any of these questions is no.
|
Signature and designation of assessors:
|
Assessor A
|
Assessor B
| |
