Criteria to determine brain death

What are the criteria to determine brain death? 

The determination of brain death can be considered to consist of four steps:

1. The clinical evaluation (prerequisites).

a. Establish irreversible and proximate cause of coma.

i. Establish by history, examination, neuroimaging, and laboratory tests.

ii. Exclude the presence of a CNS-depressant drug effect by history, drug screen, calculation of clearance using five times the drug’s half-life (assuming normal hepatic and renal function), or, if available, drug plasma levels below the therapeutic range.

iii. Prior use of hypothermia (e.g., after cardiopulmonary resuscitation for cardiac arrest) may delay drug metabolism.

iv. Blood alcohol content <0.08%) is a practical threshold below which an examination to determine brain death could reasonably proceed.

v. No recent administration or continued presence of neuromuscular blocking agents (assessed by the presence of a train of four twitches with maximal ulnar nerve stimulation).

vi. No severe electrolyte, acid–base, or endocrine disturbance (defined by severe acidosis or laboratory values markedly deviated from the norm).

vii. Achieve normal core temperature >36° C.

viii. Systolic blood pressure ≥100 mm Hg.

2. The clinical evaluation (neurologic assessment).

a. Presence of coma.

b. Absence of brain stem reflexes.

c. Apnea as demonstrated by an apnea test.

3. Ancillary tests: EEG, cerebral angiography, nuclear scan, TCD, CTA, and MRI/MRA. Brain death is a clinical diagnosis. Ancillary testing can be used when uncertainty exists about the reliability of parts of the neurologic examination or when the apnea test cannot be performed.

4. Documentation. The time of brain death is documented in the medical records.

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