CICM SAQ 2012.2 Q17

1. Apart from identifying evidence of sufficient intracranial pathology, list the preconditions that must be met prior to the determination of brain death by clinical criteria

• Minimum period of 4 hours in which the patient is observed to have unresponsive coma, unreactive pupils, absent cough/tracheal reflex and no spontaneous respiratory effort
• Normothermia (temp >35oC)
• Normotension (SBP >90 mmHg, MAP >60 mmHg in adult)
• Exclusion of sedative drugs
• Absence of severe electrolyte, metabolic or endocrine disturbance
• Intact neuromuscular function
• Ability to examine the brainstem reflexes including at least one ear and one eye
• Ability to perform apnoea testing

2. What is the recommended minimum time for observation in cases of hypoxic- ischaemic brain injury, prior to performing clinical testing of brain-stem function?

•  24hours

3. For each of the following brainstem reflexes, list the cranial nerves that are tested:

• Cough reflex – cranial nerve X
• Vestibulo-ocular reflex -cranial nerve III,IV,VI,VIII
• Pupilary light reflex – cranial nerve II & III
• Corneal reflex – cranial nerve V & VII
• Gag reflex – cranial nerve IX & X

(for each part of this question ALL cranial nerves are required in order to receive the 5 marks, no marks should be given for an incomplete response)

4. List three contra indications to performing apnoea testing

• a. Concomitant high cervical cord injury
• b. Severe hypoxaemia
• c. Haemodynamic instability

5. List the acceptable imaging techniques that may be used to demonstrate brain death as an alternative to clinical testing as recommended by the ANZICS Statement on Death and Organ Donation.

• Four vessel intra-arterial catheter angiography with digital subtraction (preferred)
• Radionuclide imaging with Tc-99m HMPAO and single photon emission computerised tomography (SPECT) (preferred)
• CT angiography (limited experience to date) (acceptable)