Brain Death Testing

• Prerequisites: known irreversible cause with confounders excluded (sedatives, hypothermia >36 °C, metabolic, paralytics).
• The exam requires coma, absent brainstem reflexes (pupils, corneal, oculocephalic/vestibular, gag, cough), and an apnea test showing PaCO₂ ≥60 or a +20 rise.
• If the exam stays incomplete, add ancillary tests (EEG, CTA/TCD, perfusion).
• Involve organ procurement early; good donor management preserves options for families.

Determining Death by Neurologic Criteria

• Homeostatic factors normal? (SBP ≥100 mm Hg or MAP ≥75 mm Hg · core temperature ≥36°C · serum electrolytes acceptable, e.g., sodium >120–130 and <160–170 · normal acid–base balance)
• Heating blankets to raise core temperature >36°C · fluids and vasopressors for hypotension · fix electrolyte abnormalities · restore acid–base balance (bicarb, adjust vent)
• Still comatose?
• History pointing to a drug effect? (drug overdose — prescription, recreational · persistent sedation or anesthetic effect · neuromuscular blockade)
• Run appropriate drug screens; if positive, allow 4–5 half lives of the agent to clear; check train-of-four · consider dialysis or other reversing agents
• Criteria for brain death not met
• Brainstem reflex exam: confirm deep coma and complete unresponsiveness to painful stimuli using supraorbital, temporo-mandibular, or nail-bed pressure in at least two locations · pupils unresponsive to light in a dark room · lightly brush each cornea with soft cotton tip or saline drops to confirm no reflexive eye closing · no eye movements on caloric testing with head tilted 30 degrees up and each tympanum irrigated with a total of 50 mL ice water · tracheal suctioning confirms absent cough
• All reflexes absent?
• Apnea test: temperature ≥36°C and SBP ≥100/MAP ≥75 mm Hg (if high-dose vasopressors, high PEEP or FiO₂ required, use other confirmatory tests) · pre-oxygenate with 100% FiO₂ for 10 minutes; check baseline pCO₂ (adjust vent as needed) · disconnect ventilator, pass catheter through the ETT to the carina, give oxygen at 2–6 L/min · watch chest wall for any respirations over 10–15 minutes while monitoring vital signs · check ABG: PaCO₂ ≥60 mm Hg AND ≥20 mm Hg above baseline with pH <7.30 confirms apnea
• Spontaneous breathing? (spontaneous chest or abdominal movements · ABG fails criteria for adequate pCO₂/pH stimulation)
• Criteria for brain death not met
• Any ambiguity in exam or law requiring confirmatory testing (or too unstable for apnea testing)?
• Confirmatory testing — method as required by law or hospital
• Clinical criteria for brain death met · notify organ procurement agency immediately
• Reflexes present — criteria for brain death not met
• Criteria for brain death not met