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    Coma & Brain Stem Death

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    Sunn Ren Tee
    Coma is an unarousable state of unresponsiveness, differing from sleep or syncope. Brainstem death results in irreversible loss of brain and brainstem functions including consciousness and arousal. Diagnosis involves documenting the absence of brainstem reflexes on two examinations at least 6 hours apart and failure to breathe spontaneously with rising carbon dioxide levels. Strict clinical criteria and documentation are required to determine brain death, which is legally equivalent to human death.

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    Coma & Brain Stem Death

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    Sunn Ren Tee
    80 views24 pages
    Coma is an unarousable state of unresponsiveness, differing from sleep or syncope. Brainstem death results in irreversible loss of brain and brainstem functions including consciousness and arousal. Diagnosis involves documenting the absence of brainstem reflexes on two examinations at least 6 hours apart and failure to breathe spontaneously with rising carbon dioxide levels. Strict clinical criteria and documentation are required to determine brain death, which is legally equivalent to human death.

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    Coma is an unarousable state of unresponsiveness, differing from sleep or syncope. Brainstem death results in irreversible loss of brain and brainstem functions including consciousness and arousal. Diagnosis involves documenting the absence of brainstem reflexes on two examinations at least 6 hours apart and failure to breathe spontaneously with rising carbon dioxide levels. Strict clinical criteria and documentation are required to determine brain death, which is legally equivalent to human death.

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    80 views24 pages

    Coma & Brain Stem Death

    Uploaded by

    Sunn Ren Tee
    Coma is an unarousable state of unresponsiveness, differing from sleep or syncope. Brainstem death results in irreversible loss of brain and brainstem functions including consciousness and arousal. Diagnosis involves documenting the absence of brainstem reflexes on two examinations at least 6 hours apart and failure to breathe spontaneously with rising carbon dioxide levels. Strict clinical criteria and documentation are required to determine brain death, which is legally equivalent to human death.

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    Coma & Brain stem death

    Rifdy Mohideen
    What is coma?
    Coma is a state of unarousable unresponsiveness

    •No evidence of arousal


    – no spontaneous eye opening
    – no comprehensible speech
    – no voluntary limb movement
    – No response to external stimuli & surrounding environment

    •There may be
    – abnormal postures adopted
    – eyes may open, or grunts may be elicited in response to pain
    – involuntary movements, e.g. seizures or myoclonic jerks, may
    occur.
    Coma differs from
    • Sleep (arousable)
    • Syncope (brief)
    • Stupor (aroused with repeated stimuli)

    Coma should be differentiated from


    • Locked-in syndrome: actually conscious but unable to speak or move,
    may move eyes (massive brainstem damage)

    • Vegetative state: patients appear to be awake but show no sign of


    awareness of themselves or their environment (brainstem intact but
    widespread cortical damage); may breath spontaneously
    What is consciousness?

    Consciousness is a state of awareness of self and the


    environment

    This state is determined by two separate functions:


    – awareness (content of consciousness)
    – arousal (level of consciousness )
    Coma is caused by disordered arousal rather than
    impairment of the content of consciousness

    Arousal is dependent on an intact reticular


    activating system located in the brainstem and its
    ascending connections
    Is there a way of objectively measuring
    consciousness?
    • GCS is a useful way of assessing and monitoring level
    of consciousness

    • This analyses three markers of consciousness


    – eye opening
    – motor
    – verbal responses
    Glasgow Coma Scale
    Eye Opening Score
    Spontaneous 4
    Brain injury classification
    To voice 3
    To painful stimuli 2 3 coma or death
    None 1 =<8 severe
    Motor 9-12 moderate
    Obeys commands 6 >= 13 minor
    Localises pain 5
    Withdraws to painful stimuli 4
    Flexion to painful stimuli 3 Individual responses and total
    scores important
    Extension to painful stimuli 2
    Makes no movement 1 Reported as E3 M3 V4
    Verbal Tracheal intubation and severe
    Oriented 5 eye/facial injury may invalidate
    Confused
    verbal response
    4
    Inappropriate words 3
    Unintelligible sounds 2
    Makes no sound 1
    Mechanisms of coma

    • diffuse or extensive processes affecting the


    whole brain (toxins, metabolic, ischaemic,
    infections)

    • supratentorial mass lesions causing tentorial


    herniation with brain stem compression

    • infratentorial mass lesions and vascular


    lesions
    Management of coma

    • detect and treat any immediately life-threatening


    condition

    • determine the site and cause of the lesion


    – history (eyewitness, family, friends)
    – examination (general and neurological; motor
    responses to stimuli, respiratory patterns, pupils, and
    eye movements)
    – investigations (focused)
    Brain death

    • vital functions can now be maintained artificially for


    a long period of time after the brain has ceased to
    function but is futile
    • need to diagnose brain death with utmost accuracy
    and urgency
    • brain dead is legally and clinically dead
    • ethical reasons
    • retrieval of organs
    Brain death - definition

    • an irreversible loss of all functions of the brain,


    including the brainstem
    • three essential findings
    – coma
    – absence of brainstem reflexes
    – apnoea (no spontaneous respiration)
    Brain death - pathology

    • swelling of brain and brainstem


    • tentorial and foraminal herniation
    • absence of blood flow
    • 10% of brain and 60% of spinal cord may appear
    normal
    Diagnosis of brain death

    • The diagnosis of brain death is primarily clinical

    • No other tests are required if the full clinical


    examination, including each of two assessments of
    brain stem reflexes and a single apnoea test, are
    conclusively performed
    Determination of brain death
    • history or physical examination findings
    • exclusion of conditions that might confound the subsequent examination
    of cortical or brain stem function
    • performance of a complete neurological examination including the
    standard apnea test and 10 minute apnea test
    • assessment of brainstem reflexes
    • clinical observations compatible with the diagnosis of brain death
    • responsibilities of physicians
    • notify next of kin
    • interval observation period
    • repeat clinical assessment of brain stem reflexes
    • confirmatory testing as indicated
    • certification and brain death documentation
    History & physical examination of brain
    dysfunction
    identification of the proximate cause and irreversibility of coma
    severe head injury
    massive intracerebral bleed
    aneurysmal subarachnoid hemorrhage, hypoxic-ischemic brain insults
    fulminant hepatic failure

    Exclude
    Shock/ hypotension
    Hypothermia - temperature < 32°C
    Drugs known to alter neurologic, neuromuscular function and
    electroencephalographic testing
    Medical conditions (e.g. brain stem encephalitis)
    Complete neurological examination
    • Absence of spontaneous movement, decerebrate or decorticate
    posturing, seizures, shivering, response to verbal stimuli, and response to
    noxious stimuli administered through a cranial nerve path way

    • Absent pupillary reflex to direct and consensual light

    • Absent corneal, oculocephalic, cough and gag reflexes

    • Absent oculovestibular reflex

    • Failure of the heart rate to increase by more than 5 beats per minute after
    1- 2 mg. of atropine intravenously

    • Absent respiratory efforts in the presence of hypercarbia when ventilator


    is switched off and PaCo2 rises above 6.7kPa (50mmHg) (apnoea test is
    performed after the second examination of brainstem reflexes)
    Assessment of brainstem reflexes
    • Pupils- no response to bright light (absent light reflex - cranial nerve II and
    III)
    • Ocular movement- cranial nerve VIII, III and VI
    – No oculocephalic reflex (testing only when no fracture or instability of
    the cervical spine or skull base is apparent)
    – No deviation of the eyes to irrigation in each ear with 50 ml of cold
    water (tympanic membranes intact; allow 1 minute after injection and at
    least 5 minutes between testing on each side)
    • Facial sensation and facial motor response
    – No corneal reflex (cranial nerve V and VII)
    – No jaw reflex (cranial nerve IX)
    – No grimacing to deep pressure on nail bed, supraorbital ridge, or
    temporo-mandibular joint (afferent V and efferent VII)
    • Pharyngeal and tracheal reflexes (cranial nerve IX and X)
    – No response after stimulation of the posterior pharynx
    – No cough response to tracheobronchial suctioning
    Clinical observations compatible with the
    diagnosis of brain death
    • spontaneous movements of limbs other than pathologic
    flexion or extension response
    • respiratory-like movements (shoulder elevation and
    adduction, back arching, intercostal expansion without
    significant tidal volumes)
    • sweating, flushing, tachycardia
    • normal blood pressure without pharmacologic support or
    sudden increases in blood pressure
    • absence of diabetes insipidus
    • deep tendon reflexes; superficial abdominal reflexes; triple
    flexion response
    • absent plantar reflex
    Determination of brain death contd.
    • notify next of kin
    – Consent not needed for diagnosis
    – Consent needed for removal of life support and organ donation
    • interval observation period
    – 6 hour observation period
    • repeat clinical assessment of brain stem reflexes
    – Repeated in full and documented
    • confirmatory testing as indicated but is not routine
    • 2 physicians required for certification (organ donation)
    Medical Record Documentation
    • etiology and irreversibility of coma / unresponsiveness
    • absence of motor response to pain
    • absence of brainstem reflexes during two separate
    examinations separated by at least 6 hours
    • absence of respiration with pCO2 ≥ 60 mm hg
    • justification for, and result of, confirmatory tests if
    used
    Malaysian guidelines

    • 1993 - Consensus statement on brain death


    • 2003 – Review of above statement
    – (Malaysian Society of Neurosciences)

    www.neuro.org.my/index.php?sc=allclinicalpractice

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