What do you assess for in brain death?

Doing exams for brain death is a grim task, and it’s important to be sure about your findings. If I could impart one tip, it would be: push harder than you need to, be louder than you should, and don’t do the exam half-heartedly. It will make you more confident about reporting on the patient’s status.

There is a very nice outline of the brain death exam with guidelines and numbers on UpToDate. Here are some clinical pearls I have learned along the way:

  • First off, brain death exams should be done serially, beginning at seventy-two hours
  • It’s called noxious stimuli for a reason. One attending I know has a technique she calls “the nipple twister.” Watch the pt’s movement, facial expression, BP, and heart rate to evaluate their response to pain
  • use a real flashlight to evaluate pupils
  • use a saline jet to evaluate the corneal reflex
  • really snap the head back and forth when doing a test for oculomotor reflexes. It’s different than turning the head to and fro for sound localization
  • reflexes aren’t the best indicator of higher-level activity because they can still happen at the spinal cord level
  • the family can always be in the room if they want, but warn them that the exam may distress them. Many times, the families are still in shock while we’re evaluating their loved ones for brain death and it’s important to be respectful of their own pain.
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