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To learn how to confirm the status of death

and to practice the relevant neurological examinations

Definitions: Introduction of death
Confirmation of Death The regulations of death announcement in Taiwan
General announcement of death in medical conditions
Brain death
The concept of brain death
Selection of candidates for the determination of brain
death
Exclusion criteria for the determination of brain death
Procedures for the brain death
2013.04.30 How to do the relevant neurological examinations during the
procedures of determination of brain death
Practice of the neurological examinations

(brain death, cerebral death) (brain death)

(brain stem death) 1976

1976
(decorticate)


(decerebrate)





5 6

1
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(brain death)
1983

1981 1987619

1987917


The point of no return 200489


201212173
7

1011217
0930211265
(37)3 1011217

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5. 6.


12


12
12
72

7. 8.

1) 1)
2) 955
40 mmHg
3)
2)
100
100
4)

5)
3)

60mmHg
6)
4)

9. 11.
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2)


10.
1)
2)
3)


4)

5)
()
6)
()
7)

8)

3
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12.



13.
()
()

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14.

-1

-2

4
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-1 -2

-3 -4

Pupil Innervation
Absence of brainstem reflexes ascertained
(1)Oculocephalic reflex
(2)Pupillary light reflex
(3)Corneal reflex
(4)Vestibulo-ocular reflex
(5)

Motor response within the cranial nerve distribution in
response to adequate stimulation of any somatic area
(6)
Gag reflex or reflex in response to bronchial stimulation
by a suction catheter passed down the trachea
Parasympatheticpathway Sympatheticpathway

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Pupillightreflexesatdifferentbrainlevels Theneuronal
pathwaysof
conjugateeye
movements(EOM)

III

MLF

VI
PPRF
VIII

Frontal cortex
Area 8

Mnemonic:COWS = Cold Opposite; Warm Same Nystagmus
(Vestibulo-oculoar reflex)
TechniqueandResultsofCaloricTest
Coldorwarmwaterorairisirrigatedintotheexternal
auditorycanal,usuallyusingasyringe.Thetemperature
differencebetweenthebodyandtheinjectedwatercreatesa
convectivecurrentintheendolymphofthenearbyhorizontal
semicircularcanal.Hotandcoldwaterproducecurrentsin
oppositedirectionsandthereforeahorizontalnystagmusin
oppositedirections.
Inpatientswithanintactbrainstem: Ifthewateriswarm
(44Corabove)endolymphintheipsilateralhorizontalcanal
rises,causinganincreasedrateoffiringinthevestibular
afferentnerve.Thissituationmimicsaheadturntothe
ipsilateralside.Botheyeswillturntowardthecontralateral
ear,withhorizontalnystagmustotheipsilateralear.

TechniqueandResultsofCaloricTest AbnormalEOMatdifferentbrain
Ifthewateriscold,relativetobodytemperature(30Cor levels&calorictest
below),theendolymphfallswithinthesemicircularcanal,
decreasingtherateofvestibularafferentfiring.Theeyesthen
turntowardtheipsilateralear,withhorizontalnystagmus
(quickhorizontaleyemovements)tothecontralateralear.
Absentreactiveeyemovementsuggestsvestibularweakness
y gg
ofthehorizontalsemicircularcanalofthesidebeing
stimulated.
Incomatosepatientswithcerebraldamage,thefastphaseof
nystagmuswillbeabsentasthisiscontrolledbythecerebrum.
Asaresult,usingcoldwaterirrigationwillresultindeviation
oftheeyestowardtheearbeingirrigated.Ifbothphasesare
absent,thissuggeststhepatient'sbrainstemreflexesarealso
damagedandcarriesaverypoorprognosis.

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CornealReflex
Hemispheric lesion

Localized pain with hemiplegia

Diencephalic (subcortical) lesion

Decorticate posture
Midbrain-upper pontine lesion Lower pontine-medullary lesion
CN 5
CN 7

Decerebrate posture Knee flexion

37
Posturingatdifferentbrainlevels

Respiratory
patternsat (1)100%10 (Preoxygenate with
100% O2 for 10 minutes)
differentbrain (2)95%5%5PaCO2
40 mmHg(Administer 5% CO2 in 95% O2 for 5 minutes
levels to ensure pre-testing PaCO2 of 40 mmHg)
(3)100%
6(Disconnect the ventilator and insufflate the
trachea with 100% O2 at 6 L/min through the
intratracheal catheter passed to the carina)
(4)10PaCO2
60 mmHg(Maintain disconnection for 10 minutes and
check arterial blood gas to ensure final PaCO2 over 60
mmHg)
(5)(Absolute apnea ascertained)
Apnea
C1-C4