Observations Compatible and Incompatible with Brain Death

Reviewed and revised 25 June 2012


  • To make the diagnosis of brain death the examiner must be able recognise responses that do not require brain function
  • stimulus-provoked movements should be termed reflexes and spontaneous movements termed automatisms
  • brain death-associated automatisms may be present in up to 50% of brain death cases


  • spinal reflexes (spontaneous or elicited by stimulation) including the following:
    • extension-pronation movements of upper limbs
    • non-specific flexion of lower limbs
    • undulating toe reflex
    • Lazarus sign ( raising both arms briefly by flexing at the elbows before dropping them onto the chest at painful stimulation)
    • deep tendon reflexes
    • plantar responses
    • respiratory like movements without significant tidal volumes
    • head turning
    • ‘thumb’s up sign’
  • sweating
  • blushing
  • tachycardia
  • normal blood pressure without need for pharmacological support
  • absence of diabetes insipidus


  • decerebrate or decorticate posturing
  • true extensor or flexor motor responses to painful stimuli (at either a cranial nerve or somatic nerve site)
  • seizures

References and Links

  • ANZICS Statement on Death and Organ Donation – 3.2 (2013)
  • Jain S, DeGeorgia M. Brain death-associated reflexes and automatisms. Neurocrit Care. 2005;3(2):122-6. PubMed PMID: 16174880.
  • Saposnik G, Basile VS, Young GB. Movements in brain death: a systematic review. Can J Neurol Sci. 2009 Mar;36(2):154-60. Review. PubMed PMID: 19378707.

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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