What is the difference betweenan anatomic coma and a

metabolic coma? Examples.

1a

-An anatomic coma involves 【mechanicaldestruction】 of the brainstem or cerebralcortex (i.e.: hemorrhagic stroke, caraccident)-A metabolic coma is 【global disruptionof metabolic processes】 (i.e.: electrolyteimbalance)

1b

What are the requirementsunder the state *regulations fordetermining brain death? Name

5

2a

- 【a QUALIFIED PHYSICIAN】-Physician acts in good faith (【not part oftransplant team】 imposing a conflict ofinterest)-【Number of physicians (at least 2)】-Religious exemption-Medical standards

2b

Although there is no goldstandard about what constitutesbrain death, how is it generally

determined.

3a

Bedside & clinical diagnosis

3b

Clinical diagnosis of brain deathcan be made without

confirmatory testing if you areable to:

4a

-Establish the 【etiology】-【Eliminate reversible causes】 of

coma-Complete fully the 【neurological

exam & apnea testing】4b

Diagnosis of brain death requiresdemonstration of the absence of

both____and___activity

5a

Cortical and Brain stem (moresubjective as opposed to

objective)

5b

What is the hospital policy forbrain death? *

6a

-Requires 2 independent exams-A neurologist or neurosurgeonmust perform one of the exams-Document exam in medical record-Determination is made in ICU

6b

Which irreversible states canproduce brain death?

7a

-Head Trauma-Intracranial hemorrhage

-Brain tumor-Cerebral edema

-Hypoxia-Cerebrovascular injury

7b

What are the contraindicationsaddressed/corrected prior to

diagnosing brain death?

8a

-Hypothermia-Hypotension-Drug overdose/toxicity, poisoning, orneuromuscular blocking agents-Severe electrolyte, endocrine, acid-base imbalance-Locked-in syndrome-Postical state (following severe tonic -clonicseizure)

8b

What medical criteria is requiredprior to a brain dead diagnosis?

3

9a

-Absence of【cerebral function】(all lobes must be assessed)

-Absence of 【brain stemfunction】 (CN assessment)

-【Apnea】9b

absence of cerebral function?Characteristics? *

10a

-Total unresponsiveness to visual,auditory, and central pain-No spontaneous movement (swallowing,yawning)-No vocal response-No cough-Lazarus sign

10b

What is a Lazarus sign?

11a

【Spinal cordreflexes】compatible with braindeath diagnosis; mainly seen in

teenagers and children

11b

What are the steps taken indiagnosis a brain stem function?

12a

-Fixed, nonreactive pupils-Absence of spontaneous eye movement-Absence of oculovestibular reflex &oculocephalic response (CN 3, 6, 8)-Absent gag reflex (CN 9 & 10)-Absent cough reflex-Absent corneal reflex (5 & 7)-Absence of respiratory function

12b

How is the oculovestibular reflexperformed? Interpretation of

results?

13a

ice h20 placed in eardrum. If thereis a brainstem injury, the eyes wouldstay midline and if the brainstem isintact, the eyes will go the oppositeway【cOld = Opposite, Warm = With】

13b

How is the oculocephalicresponse done?

14a

Open eyelids and turn head sideto side

14b

What corresponds to an absenceof respiratory function?

Characteristics? *

15a

No evidence of spontaneousbreathing

15b

Apnea Test Prerequisites

16a

Core Body Temp ≥ 36.5°C or 97°FSBP ≥90 mmHgDI under control (positive fluid balance for past6 hours)pCO2 must be normal (arterial ≥40 mmHg)Pre-oxygenation up to arterial pO2 ≥ 200 mmHg

16b

How is the absence of respiratoryfunction determined? STEPS.

17a

-Apnea test1. Preoxygenate (100%)2. Baseline ABG (to see what the CO2 is)3. Disconnect ventilator (but do not take oxygen away)4. Administer oxygen5. Observe respirations 6. Draw ABG (8-10 min)7. A pCO2 of ≥ 60 mmHg or an increase of ≥ 20 mmHg overa normal baseline with no respiratory effort supports apositive apnea test and is consistent with brain death.

17b

Why would the apnea test beaborted?

18a

-Patient breaths-HD instability

-Hypoxia-Arrhythmia

18b

What would be the bestconfirmatory test for brain

death? What would itdemonstrate?

19a

Cerebral Blood flow- nuclearscan; No uptake of radionuclide

in brain parenchyma "hollowskull phenomenon"- NO FLOW

19b

Why is an EEG not typically doneas a confirmatory test?

20a

Because it can show artifacts

20b

Describe the process related toorgan donation. *

21a

-Ensure the option of anatomical donation ispresented to the family on all deaths-Hospital must notify OPO of individuals whosedeath is imminent or who have died in thehospital-OPO determines medical suitability -Hospital and OPO will work collaboratively

21b

How are the organs of donorsmanaged?

22a

-Optimize oxygenation-Prevent pulmonary complications-Maintain body temps-Hemodynamic stability (BP)-Fluid & electrolyte balance

22b

1 donor has the potential tosave____lives

23a

8

23b

What ancillary test has not beenvalidated for use as aconfirmatory test yet?

24a

Computed TomographyAngiogram (CTA/MRI)

24b

When can one perform anancillary test without the 3

standard components of DNC? 3Reasons

25a

-Apnea test is aborted-Drug toxicity

-Cant correct metabolicdysfunctions

25b

Can the death by neurologicalcriteria be determined if there isno cause for irreversible injury?

26a

No

26b

What PCO2 levels would supporta diagnosis of DNC?

27a

If the pCO2 rises to greater than 60mmHg or20mmHg higher than the pretest pCO2 and thepatient has no respiratory effort, the testsupports the diagnosis of death by neurologicalcriteria.

27b

The transcranial doppler test(TCD) looks for?

28a

The abnormalities include a lackof diastolic or reverberation flowand documentation of smallsystolic peaks in early systole.

28b