Brain stem death

Forensic Medicine

1. BRAIN STEM DEATH

2. BRAIN DEATH Its of 3 types CORTICAL OR CEREBRAL DEATH BRAINSTEM DEATH WHOLE BRAIN DEATH

3. BRAIN STEM DEATH Brain stem death  is a clinical syndrome defined by the absence of reflexes with pathways through the  brain stem  - the “stalk” of the brain, which connects the spinal cord to the mid-brain, cerebellum and cerebral hemispheres.

4. Loss of vital centres that control respiration and of ARAS that retain consciousness ------ > victim is irreversibly comatose and incapable of spontaneous breathing (apnoeic). i.e. brainstem death is when a person no longer has any activity in their brainstem , and has permanently lost the potential for consciousness and the capacity to breathe.

5. Can be produced by Raised intra cranial pressure Cerebral edema Intracranial hemorrhage etc.

6. VARIOUS CRITERIA FOR DETERMINING BRAIN DEATH

7. HARVARD CRITERIA

8. 1. Unreceptivity and unresponsivity Total unawareness to external stimuli and inner need Complete unresponsiveness to even most intense painful stimuli

9. 2. No movements No spontaneous muscular movements in response to stimuli such as: Pain Touch Sound Light - for atleast 1 hour

10. 3. Apnoea Absence of complete breathing for one hour If patient is on ventilator, total absence of spontaneous breathing is established by turning off the respirator for 3 minutes and observing whether there is any effort from the subject to breathe spontaneously

11. 4. Absence of elicitable reflexes Pupils are fixed and dilated, does not respond to light Ocular movement and blinking absent No evidence of postural activity Corneal and pharyngeal reflexes absent Stretch tendon reflexes also lost

12. 5. Isoelectric EEG Confirmatory test

13. All the tests should be repeated after 24 hours with no change in results.

14. Two schools of diagnosing death : French and English school – similar to Harvard Austro-German school – includes Harvard criteria and bilateral serial angiography of internal carotid and vertebral artery criteria. - a negative angiogram for more than 15 minutes proves death

15. DIAGNOSIS OF BRAINSTEM DEATH EXCLUSIONS Patient may be under effect of drugs, eg :- therapeutic overdoses. Core temperature of body is below35 o C, hypothermia. Severe metabolic or endocrine disturbances that may lead to severe irreversible coma, eg :- diabetes.

16. PRECONDITIONS OF DIAGNOSIS Patient must be deeply comatose Patient must be maintained on a ventilator Cause of the coma must be known

17. PERSONNEL WHO SHOULD PERFORM THE TESTS Must be performed by 2 medical practitioners Doctors involved should be experts Transplant surgeons under no circumstances can perform the test At least one of the doctors should be of consultant status, junior doctors are not allowed Each doctor should perform the test twice

18. TESTS TO BE PERFORMED Before the tests, it is ensured that core temperature of body is above 35 o C Cranial nerves that pass through brain stem are tested.

19. Pupils are fixed in diameter and do not respond to changes in intensity of light No corneal reflex Vestibulo-ocular reflexes are absent (no ocular movement after instillation of cold water into outer ears) No motor responses within the cranial nerve distribution can be elicited by painful stimulation No gag reflex No respiratory movements occur when patient is disconnected from ventilator (long enough to ensure CO 2 concentration rises above the threshold to stimulate respiration)

20. When two doctors have performed these tests twice with negative results, the patient is pronounced dead and a death certificate can be issued.

21. Thank you…