CICM SAQ 2012.2 Q17

Questions

With regards to the determination of brain death:

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

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?

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

  • Cough reflex
  • Vestibulo-ocular reflex
  • Pupilary light reflex
  • Corneal reflex
  • Gag reflex

4. List three contra indications to performing apnoea testing

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.


Answers

Answer and interpretation

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)

Exams LITFL ACEM 700

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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and 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 two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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