Brain Death

Physiology

Dr. Bernhard Arianto Purba, M.Kes., AIFO

 Textbooks
Robert L. Kane, Joseph G. Ouslander, and Itamar B. Abrass. 2004. Essentials of
Clinical Geriatrics. 5th Edition. USA: McGraw-Hill .
Edmund H. Duthie Jr, Paul R. Katz, and Michael L. Malone. 2007. Duthie: Practice of
Geriatrics. 4th ed. USA: Saunders, an imprint of Elsevier Inc.
Christine K. Cassel. 2002. Geriatric Medicine: An Evidence-Base Medicine. 4th ed.
New York, inc : Spinger-Ver-Lag.
Mark H. Beers, and Robert Berkow. 2001. The Merck Manual of Geriatrics. USA:
Whitehouse Station, NJ.
J. Grimely Evans. 2000. Oxford Textbook of Geriatric Medicine (Oxford Medical
Publications). USA: Oxford University Press.
Guyton, A.C & Hall, J.E. 2006. Textbook of Medical Physiology. The 11th edition.
Philadelphia: Elsevier-Saunders.
Marieb, E.N., and Hoehn, K. 2007. Human Anatomy and Physiology. The 7th
edition. USA: Benjamin Cummings, Pearson Educaton, Inc.
Brooks, G.A. & Fahey, T.D. 1985. Exercise Physiology. Human Bioenergetics and Sts
Aplications. New York : Mac Millan Publishing Company.
Foss, M.L. & Keteyian, S.J. 1998. Foxs Physiological Basis for Exercise and Sport.
4th ed. New York : W.B. Saunders Company.
Astrand, P.O. and Rodahl, K. 1986. Textbook of Work Pysiology, Physiological Bases
of Exercise. New York : McGrawHill.
Banerjee, Ashis. 2005. Clinical Physiology. Cambridge: Cambridge University Press.
Fox. 2003. Human Physiology . The 6the dition. New York : McGrawHill
McPhee, S.J, and Ganong, W.F. 2006. Pathophysiology of Disease: An Introduction
to Clinical Medicine. The 5th edition. USA: McGrawHill.
Historical Perspective

Prior to the advent of mechanical

respiration, death was defined as
the cessation of circulation and
breathing
Cardoiovascular System
 Definition of Brain Death

Complete absence of cerebral and

brain stem function , but not spinal cord
function
 Historical Perspective
1959 Coma depasse Mollaret and Goulon

1968 Irreversible Coma/Brain Death Harvard

Medical School Ad Hoc Committee

1981 Uniform Determination of Death Act -

Presidents Commission for the Study of Ethical
Problems in Medicine

1994 American Academy of Neurology Guidelines

for the determination of Brain Death

2005 NYS Guidelines for Determining Brain Death

 Brain Death Current
Consensus

Absent Cerebral Function

Absent Brainstem Function

Apnea
Normal Brain Anatomy
 Normal Brain Anatomy

Cerebral Cortex

Reticular
Activating
Brain Stem System
 Cerebral Cortex
Cognition
Voluntary
Movement
Sensation
GCS: E4V5M6
Eye : 1-4 (open eye: N.III)
Verbal : 1-5 (Cerebrum)
Motorik : 1-6 (Cerebrum)
Brain Stem
Brain Stem

Midbrain
Cranial Nerve III
pupillary function
eye movement
Brain Stem

Pons
Cranial Nerves IV, V, VI
conjugate eye
movement
corneal reflex
Brain Stem

Medulla
Cranial Nerves VIII, IX, X
Caloric test
Pharyngeal (Gag) Reflex
Tracheal (Cough) Reflex
Respiration
 Reticular Activating
System

Receives multiple
sensory inputs

Mediates
wakefulness
Causes of Brain Death

Normal Cerebral Anoxia

Causes of Brain Death

Normal Cerebral Hemorrhage

Causes of Brain Death

Normal Subarachnoid
Hemorrhage
Causes of Brain Death

Normal Trauma
Causes of Brain Death

Normal Meningitis
Mechanism of Cerebral
Death

ICP>MAP is
incompatible
with life

Increased Intracranial
Pressure
 Conditions Distinct
From Brain Death

Persistent Vegetative State

Locked-in Syndrome

Minimally Responsive State

 Persistent Vegetative
State

Normal Sleep-Wake Cycles

No Response to Environmental
Stimuli

Diffuse Brain Injury with

Preservation of Brain Stem
Function
Locked-in Syndrome
a.k.a cerebromedullospinal disconnection

Ventral Pontine
Infarct
Complete Paralysis

Preserved
Consciousness

Preserved Eye
Movement
Minimally Responsive
State
Static Encephalopathy

Diffuse or Multi-Focal Brain Injury

Preserved Brain Stem Function

Variable Interaction with

Environmental Stimuli
 Brain Death
Neurological
Examination
Clinical Prerequisites:

Known Irreversible Cause

Exclusion of Potentially Reversible

Conditions
Drug Intoxication or Poisoning
Electrolyte or Acid-Base Imbalance
Endocrine Disturbances

Core Body temperature > 32 C

 Brain Death
Neurological
Examination
Coma

Absent Brain Stem Reflexes

Apnea
 Coma

No Response to Noxious Stimuli

Nail Bed Pressure

Sternal Rub

Supra-Orbital Ridge Pressure

 Absence of Brain Stem
Reflexes
Pupillary Reflex

Eye Movements

Facial Sensation and Motor

Response

Pharyngeal (Gag) Reflex

 Pupillary Reflex

Pupils dilated with no constriction to bright

light
Eye Movements

Occulo-Cephalic
Response
Dolls Eyes Maneuver
 Eye Movements

Oculo-Vestibular Response
Cold Caloric Testing
 Facial Sensation and
Motor Response
Corneal Reflex

Jaw Reflex
Grimace to Supraorbital or
Temporo-Mandibular Pressure
 Apnea Testing

Prerequisites

Core Body Temperature > 32 C

Systolic Blood Pressure 90 mm

Hg

Normal Electrolytes

Normal PCO2
 Apnea Testing

1. Pre-Oxygenation
100% Oxygen via Tracheal Cannula
PO2 = 200 mm Hg

2. Monitor PCO2 and PO2 with pulse oximetry

3. Disconnect Ventilator
4. Observe for Respiratory Movement until
PCO2 = 60 mm Hg
5. Discontinue Testing if BP < 90, PO2
saturation decreases, or cardiac dysrhythmia
observed
 Confounding Clinical
Conditions
Facial Trauma

Pupillary Abnormalities

CNS Sedatives or Neuromuscular

Blockers

Hepatic Failure
 Observations
Compatible with Brain
Death
Sweating, Blushing

Deep Tendon Reflexes

Spontaneous Spinal Reflexes- Triple

Flexion

Babinski Sign
Confirmatory Testing

Recommended when the

proximate cause of coma is not
known or when confounding
clinical conditions limit the clinical
examination
 Confirmatory Testing
EE
G

Normal Electrocerebral
 Confirmatory Testing

Cerebral
Angiography

Normal No Intracranial
 Confirmatory Testing

Technetium-99 Isotope Brain Scan

 Confirmatory Testing

MR- Angiography
Confirmatory Testing

Transcranial
Ultrasonography
Confirmatory Testing

Somatosensory Evoked Potentials

Concern for man and his fate must
always form the chief interest of all
technical endeavors. Never forget
this in the midst of your diagrams
and equations.

Albert Einstein
the Big Picture

decomposition/putrefaction

life death skeletal remains*

CoD/ToD taphonomy
* or mummification
And all this
science, I
dont
understand.
Its just my
job, five
days a
week.
Elton John from Rocket Man
TERIMAKASIH