Brain Death


  • Brain death is the irreversible loss of all functions of the brain, including the brainstem
  • The three essential findings in brain death are coma (unresponsiveness), absence of brainstem reflexes, and apnoea

Important considerations in the determination and management of brain death are:

  • Preconditions for diagnosis of brain death
  • Examination
  • Investigations
  • Pathophysiology
  • Management and organ donation process


  • cause for coma consistent with brain death
  • at least 4 hours of observation during which preconditions must be met (GCS 3, pupil non-reactive, no cough, apnoea)
  • neuro-imaging consistent with acute brain pathology that could cause brain death
  • normothermia (T>35C)
  • normotension (SBP>90 or MAP>60mmHg in an adult)
  • no sedation or analgesia (dependent on types of drugs used, renal and hepatic function; use antagonists if concerned)
  • absence of severe electrolyte, metabolic and endocrine disturbances (glucose, Na+, PO43-, Mg2+, renal and hepatic function)
  • no paralysis (use NMJ monitor or electromyography if concerned)
  • ability to assess brain stem reflexes (at least one eye and ear)
  • ability to perform apnoea test (doesn’t have severe hypoxic respiratory failure or have a high cervical spine injury)



  1. absence of responsiveness
  2. absence of brainstem reflexes
  3. apnoea


  • ‘Train of Four’ nerve stimulation test (40 mV) to rule out neuromuscular blockade
  • GCS 3 – no response in CN distribution (supraorbital compression) and deep nail bed pain in all four limbs
  • pupils fixed, no reaction to light (CN II, III)
  • no corneal reflex (CN V, VII)
  • no oculo-vestibular reflexes (CN III, IV, VI, VIII)
  • no gag (CN IX, X)
  • no cough (CN X)
  • positive apnoea test (after preoxygenation, and pH 7.3, no breath taken after disconnection from ventilator with a PaCO2 > 60mmHg; or increase in PCO2 by 20 mmHg if COPD/ CO2 retainer)
  • independent examination by 2 suitably trained and experienced doctors
  • can be sequential (don’t have to wait 2 hours between testing)
  • time of death is the time of completion of the second examination

Video: Brain Stem Testing – A Demonstration

Note that the legal requirements differ in the UK, however the physical examination elements of brain death testing are similar.


  • the indication for cerebral perfusion imaging is when clinical brain death can not be determined (any of the preconditions can not be met)
  • an investigation showing absent cerebral parenchymal blood flow is required:
    1. 4 vessel angiogram (no flow above the carotid siphon in anterior circulation and foramen magnum in posterior circulation)
    2. Tc-99 HMPAO SPECT radionuclide imaging (lack of perfusion across the BBB to be retained by the brain parenchyma)
    3. CT angiography (less experience with this technique, absent enhancement at 60 seconds in different cerebral arterial distributions, presence of contrast in external carotid artery must occur to establish a technically adequate study)
  • transcranial doppler (TCD) may be used as a screening test optimise the timing of the contrast study (TCD can rule out brain death, but cannot confirm it)


  • brain death is generally preceded by increasing intracranial pressure
  • following brain death a predictable pattern of multi-organ failure ensues


  • Initial Cushing’s response usually occurs (bradycardia, hypertension)
  • Dysrhythmias (‘catecholamine storm’; myocardial damage; reduced coronary blood flow)
  • Hypotension (vasoplegia; hypovolaemia; reduced coronary blood flow; myocardial dysfunction; DI)
  • Pulmonary edema (acute blood volume diversion; capillary damage)


  • Hypothermia (hypothalamic damage; reduced metabolic rate; vasodilation and heat loss)
  • Diabetes insipidus (posterior pituitary damage)
  • Endocrine dysfunction (hyperglycemia, sick euthyroid state, anterior pituitatry function usually maintained)
  • DIC (tissue factor release; coagulopathy)
  • SIRS


References and Links

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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