Sun28November0440PM 26

The diagnosis of brain stem death requires the following:

True / False

'Doll's eye' movements must be absent Correct

The core temperature must not be below 37°C Correct

Spinal reflexes must be absent Correct

The pupils must be fixed and dilated Incorrect answer selected

At least two sets of tests must be performed 24 hours apart Correct

Explanation

Brain stem death (BSD) is confirmed by demonstrating the absence of brain stem reflexes, and is characterised by profound coma. An independent existence is impossible after BSD. Before the tests can be performed, several preconditions must be met unequivocally:

the presence of apnoeic coma

a defined cause of severe and irreversible brain damage and

the exclusion of potentially reversible conditions which can mimic BSD (hypothermia can mimic BSD, so the core temperature must be above 34°C).

The tests must be performed by two doctors and then repeated following an interval determined by the clinical condition of the patient (not 24 hours apart).

The confirmatory tests include:

fixed unresponsive pupils with absence of both the direct and consensual light reflexes (the pupils do not have to be dilated and pupil size is not a factor)

absent corneal reflexes

absent vestibulo-ocular reflexes

absent motor activity after painful stimulation

absent gag reflex

absence of spontaneous respiration.

Absent oculocephalic reflexes, with no Doll's eye movements (i.e. the eyes do not move on rotating the head from side to side), however this particular test is not included in "A Code of Practice for the Diagnosis and Confirmation of Death" a publication from the working party of the Academy of Medical Royal Colleges (1998).

Spinal reflexes are often retained in BSD and this is due to intact neural arcs acting independently of central control. Therefore, the absence of spinal reflexes is not required to diagnose BSD.

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