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? □ Yes Part 2. Prerequisites Irreversible and identifiable cause of coma: □ TBI □ Stroke □ Other: Examination One Examination Two Date: Time: Date: Time: Blood Pressure > 90 mmHg □ Yes □ No □ Yes □ No Body Temperature > 35 0 C (95 0 F) □ Yes □ No □ Yes □ No Significant sedative/analgesic or drug effect excluded □ Yes □ No □ Yes □ No Significant metabolic/electrolyte abnormalities excluded □ Yes □ No □ Yes □ No Neuromuscular blockade excluded □ Yes □ No □ Yes □ No Part 3. Physical examination Responsiveness/movement (excluding spinal reflexes) Unresponsive (deeply comatose) □ Yes □ No □ Yes □ No Absent movement (no spontaneous movement, no response to painful stimuli, no posturing; spinal cord reflexes acceptable) □ Yes □ No □ Yes □ No Evidence of absent brainstem function Absent pupillary light reflex □ Yes □ No □ Yes □ No Absent corneal and gag and cough reflexes □ Yes □ No □ Yes □ No Absent oculovestibular reflex □ Yes □ No □ Yes □ No Absent oculocephalic reflex (NA = not applicable) □ Yes/NA □ No □ Yes/NA □ No Part 4. Apnea Test. High spinal cord injury excluded ? □ Yes □ No: Do not perform apnea test. Ancillary test required. Pretest PaCO2: _______ mm Hg Posttest PaCO2: _______ mm Hg Duration of test:_____________ minutes Respiratory effort? Yes No Apnea test confirms apnea? Yes No Part 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 No Absence of intracerebral blood flow demonstrated by: Cerebral angiography Radionuclide (nuclear) angiography Part 6. Signatures Examiner One: I certify that my examination is consistent with brain death. Confirmatory exam pending.
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- Summer '07
- Apnea, Brain death, pupillary light reflex, Vestibulo-ocular reflex