Brain Death Examination Form for Adults Age 18 and Older *(*For Trauma Patients Age 15 or Older, May Use Either Adult or Pediatric Guidelines)Part 1. Notify WRTC prior to brain death examination or testing. WRTC notified? □ YesPart 2. PrerequisitesIrreversible and identifiable cause of coma: □ TBI □ Stroke □ Other:Examination OneExamination TwoDate: Time:Date: Time:Blood Pressure > 90 mmHg□ Yes□ No□ Yes□ NoBody Temperature > 350C (950F)□ Yes□ No□ Yes□ NoSignificant sedative/analgesic or drug effect excluded □ Yes□ No□ Yes□ NoSignificant metabolic/electrolyte abnormalities excluded□ Yes□ No□ Yes□ NoNeuromuscular blockade excluded□ Yes□ No□ Yes□ NoPart 3. Physical examinationResponsiveness/movement (excluding spinal reflexes)Unresponsive (deeply comatose)□ Yes□ No□ Yes□ NoAbsent movement (no spontaneous movement, no response to painful stimuli, no posturing; spinal cord reflexes acceptable)□ Yes□ No□ Yes□ NoEvidence of absent brainstem functionAbsent pupillary light reflex□ Yes□ No□ Yes□ NoAbsent corneal and gag and cough reflexes□ Yes□ No□ Yes□ NoAbsent oculovestibular reflex □ Yes□ No□ Yes□ NoAbsent oculocephalic reflex (NA = not applicable) □ Yes/NA□ No□ Yes/NA□ NoPart 4. Apnea Test.High spinal cord injury excluded? □ Yes □ No: Do not perform apnea test. Ancillary test required. PretestPaCO2: _______ mm Hg PosttestPaCO2: _______ mm Hg Duration of test:_____________ minutesRespiratory effort? Yes NoApnea test confirms apnea? Yes NoPart 5. Ancillary Testing (if necessary)Ancillary tests (Cerebral Angiography or Radionuclide Imaging) -Required when minimum clinical criteria not met and full clinical examination unable to be performed (with exception for oculocephalic reflex).Ancillary Testing performed? Yes NoAbsence of intracerebral blood flow demonstrated by:Cerebral angiography Radionuclide (nuclear) angiography Part 6. SignaturesExaminer One:I certify that my examination is consistent with brain death. Confirmatory exam pending.