Ancillary Testing performed? Yes No Absence of intracerebral blood flow or lack of brain activity demonstrated by: Cerebral angiography Radionuclide (nuclear) angiography EEG Part 6. Signatures Examiner One: I certify that my examination is consistent with brain death. Confirmatory exam pending. Printed name:___________________________Signature:________________________Date:__________Time:_________ Examiner Two: I certify that my examination confirms brain death at the date and time listed below. Printed name:___________________________Signature:________________________Date:__________Time:_________ Patient Label Inova Fairfax Hospital Brain Death Examination Form
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In formation for Completing the Determination of Brain Death Assessment Clinical Criteria Details Notify WRTC (703-641-0100) The Clinical Team should notify WRTC of any patient on whom brain function testing is being considered. Date Date of examination. Time For children less than 18 years of age and 31 days of age or older (at least 36 week gestation): Two separate clinical exams must be performed at least 12 hours apart. For infants age 30 days or less and older than seven days of age (at least 36 week gestation): Two separate clinical exams must be performed at least 24 hours apart. For Adults Age 18 and older and Trauma Patients Age 15 and older , two separate exams must be performed by two physicians independently, with no specified time interval. For non-trauma patients less than 18 years of age, please use the Pediatric brain death examination form. Blood Pressure SBP should be greater than 90 mm Hg in adults & greater than the age appropriate minimum in newborns, infants, and children. Body Temperature Body temperature should be above 35 degrees C (95 F) prior to physician exam for adults and children. Neuroactive drugs worn off e.g. narcotics, sedatives, barbiturates, atropine, etc. Absence of Confounding Factors Significant electrolyte, metabolic or endocrine abnormalities. Physical examination requirements No responsiveness Patient should be deeply comatose with no responsiveness to noxious stimuli (e.g., supraorbital, sternal pressure). No movement Patient should not demonstrate any movement (spontaneously or to painful stimuli), including seizures, shivering, or posturing. Neuromuscular blocking agents and sedatives must be worn off. Spinal reflexes, including Babinski, are not indicative of brainstem function and hence may coexist with a diagnosis of brain death.
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- Summer '07
- Apnea, Brain death, pupillary light reflex, Vestibulo-ocular reflex