Tanda Klinik Fase Diensefalik.

Tanda Klinik Fase Diensefalik.

Tanda Klinik Fase Midbrain Pons Atas.

Tanda Klinik Herniasi Unkus Fase Dini N. III

Tanda Klinik Herniasi Unkus Fase Lanjut N.III

Tanda Klinik Fase Midbrain Pons Bawah

Cardiac death:

Heartbeat and breathing stop

Irreversible cessation of all functions of the entire brain, including the brain stem

Brain death:

First introduced in a 1968 report authored by a special committee of the Harvard Medical School Adopted in 1980, with modifications, by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research, as a recommendation for state legislatures and courts The "brain death" standard was also employed in the model legislation known as the Uniform Determination of Death Act, which has been enacted by a large number of jurisdictions and the standard has been endorsed by the influential American Bar Association.

1. Clinical or radiographic evidence of an acute catastrophic cerebral event consistent w/ dx of brain death 2. Exclusion of conditions that confound clinical evidence (i.e.-metabolic) 3. Confirmation of absence of drug intoxication or poisoning

Also barbiturates, NMBs

4. Core body temp >32oC (we use 34oC)

Cerebral motor response to pain

Supra-orbital ridge, the nail beds, trapezius Motor responses may occur spontaneously during apnea testing (spinal reflexes) Spinal reflex responses occur more often in young If pt had NMB, then test w/ train-of-four

Spinal arcs are intact!

Round, oval, or irregularly shaped Midsize (4-6 mm), but may be totally dilated Absent pupillary light reflex
Although drugs can influence pupillary size, the light reflex remains intact only in the absence of brain death IV atropine does not markedly affect response Paralytics do not affect pupillary size Topical administration of drugs and eye trauma may influence pupillary size and reactivity Pre-existing ocular anatomic abnormalities may also confound pupillary assessment in brain death

Oculocephalic reflex = dolls eyes Vestibulo-ocular = cold caloric test

Oculocephalic reflex

Rapidly turn the head 90 on both sides Normal response = deviation of the eyes to the opposite side of head turning Brain death = oculocephalic reflexes are absent (no Dolls eyes) = no eye movement in response to head movement Painted vs. wooden eyes in porcelain heads

Not Barbie, but old fashioned type dolls

Elevate the HOB 30 Irrigate both tympanic membranes with iced water

Observe pt for 1 minute after each ear irrigation, with a 5 minute wait between testing of each ear Facial trauma involving the auditory canal and petrous bone can also inhibit these reflexes

Nystagmus both eyes slow toward cold, fast to midline

Not comatose Coma with intact brainstem Internuclear ophthalmoplegia Suggests brainstem structural lesion Brainstem injury / death

Both eyes tonically deviate toward cold water

Movement only of eye on side of stimulus

No eye movement

Corneal reflexes are absent in brain death

Corneal reflexes - tested by using a cotton-tipped swab Grimacing in response to pain can be tested by applying deep pressure to the nail beds, supraorbital ridge, TMJ, or swab in nose Severe facial trauma can inhibit interpretation of facial brain stem reflexes

Both gag and cough reflexes are absent in patients with brain death

Gag reflex can be evaluated by stimulating the posterior pharynx with a tongue blade, but the results can be difficult to evaluate in orally intubated patients Cough reflex can be tested by using ETT suctioning, past end of ETT

PaCO2 levels greater than 60 mmHg, 20 mmHg over baseline Technique:

Apneic oxygenation

Pre-oxygenate with 100% oxygen several min Allow baseline PaCO2 to be ~40 mmHg Place pt on CPAP or bag-ETT Observe for respiratory effort for ~6 minutes Get ABG to determine PaCO2

EEG

30 minutes

4 vessel angiography Cerebral blood flow = perfusion scan

Necessary to repeat the clinical examination after an appropriate observation period has passed Confirmatory EEG unless it is determined that there is no blood flow to the brain

Age 7 days to 2 months Two examinations 48 hours apart and one EEG Age 2 months-1 year Two examinations 24 hours apart and one EEG or perfusion scan

Repeat examination and EEG are not necessary if it is determined that there is no cerebral blood flow

1.

2. 3.

Clinical or radiographic evidence of an acute catastrophic cerebral event consistent w/ dx of brain death Exclusion of conditions that confound clinical evidence (i.e.-metabolic) Confirmation of absence of drug intoxication or poisoning

Also barbiturates, NMBs

4.

Core body temp >32oC (we use 34oC)

Cerebral motor response to pain

Supra-orbital ridge, the nail beds, trapezius Motor responses may occur spontaneously during apnea testing (spinal reflexes) Spinal reflex responses occur more often in young If pt had NMB, then test w/ train-of-four

Spinal arcs are intact!

Round, oval, or irregularly shaped Midsize (4-6 mm), but may be totally dilated Absent pupillary light reflex
Although drugs can influence pupillary size, the light reflex remains intact only in the absence of brain death IV atropine does not markedly affect response Paralytics do not affect pupillary size Topical administration of drugs and eye trauma may influence pupillary size and reactivity Pre-existing ocular anatomic abnormalities may also confound pupillary assessment in brain death

Oculocephalic reflex = dolls eyes Vestibulo-ocular = cold caloric test

Oculocephalic reflex

Rapidly turn the head 90 on both sides Normal response = deviation of the eyes to the opposite side of head turning Brain death = oculocephalic reflexes are absent (no Dolls eyes) = no eye movement in response to head movement Painted vs. wooden eyes in porcelain heads

Not Barbie, but old fashioned type dolls

Elevate the HOB 30 Irrigate both tympanic membranes with iced water

Observe pt for 1 minute after each ear irrigation, with a 5 minute wait between testing of each ear Facial trauma involving the auditory canal and petrous bone can also inhibit these reflexes

Nystagmus both eyes slow toward cold, fast to midline

Not comatose Coma with intact brainstem Internuclear ophthalmoplegia Suggests brainstem structural lesion Brainstem injury / death

Both eyes tonically deviate toward cold water

Movement only of eye on side of stimulus

No eye movement

Corneal reflexes are absent in brain death

Corneal reflexes - tested by using a cotton-tipped swab Grimacing in response to pain can be tested by applying deep pressure to the nail beds, supraorbital ridge, TMJ, or swab in nose Severe facial trauma can inhibit interpretation of facial brain stem reflexes

Both gag and cough reflexes are absent in patients with brain death

Gag reflex can be evaluated by stimulating the posterior pharynx with a tongue blade, but the results can be difficult to evaluate in orally intubated patients Cough reflex can be tested by using ETT suctioning, past end of ETT

PaCO2 levels greater than 60 mmHg, 20 mmHg over baseline Technique:

Apneic oxygenation

Pre-oxygenate with 100% oxygen several min Allow baseline PaCO2 to be ~40 mmHg Place pt on CPAP or bag-ETT Observe for respiratory effort for ~6 minutes Get ABG to determine PaCO2

EEG

30 minutes

4 vessel angiography Cerebral blood flow = perfusion scan

Absent Cerebral Function

Absent Brainstem Function

Apnea

Cerebral Cortex

Brain Stem

Reticular Activating System

Cognition Voluntary Movement Sensation

Midbrain
Cranial Nerve III pupillary function eye movement

Pons
Cranial Nerves IV, V, VI conjugate eye movement corneal reflex

Medulla
Cranial Nerves IX, X Pharyngeal (Gag) Reflex Tracheal (Cough) Reflex

Respiration

Receives multiple sensory inputs Mediates wakefulness

Normal

Cerebral Anoxia

Normal

Cerebral Hemorrhage

Normal

Subarachnoid Hemorrhage

Normal

Trauma

Normal

Meningitis

Neuronal Injury

Neuronal Swelling

ICP>MAP is incompatible with life Decreased Intracranial Blood Flow

Increased Intracranial Pressure

Persistent Vegetative State

Locked-in Syndrome
Minimally Responsive State

Normal Sleep-Wake Cycles No Response to Environmental Stimuli Diffuse Brain Injury with Preservation of Brain Stem Function

Ventral Pontine Infarct

Complete Paralysis Preserved Consciousness Preserved Eye Movement

Static Encephalopathy

Diffuse or Multi-Focal Brain Injury Preserved Brain Stem Function Variable Interaction with Environmental Stimuli

Clinical Prerequisites:

Known Irreversible Cause Exclusion of Potentially Reversible Conditions

Drug Intoxication or Poisoning Electrolyte or Acid-Base Imbalance Endocrine Disturbances

Core Body temperature > 32 C

Coma

Absent Brain Stem Reflexes

Apnea

No Response to Noxious Stimuli

Nail Bed Pressure Sternal Rub

Supra-Orbital Ridge Pressure

Pupillary Reflex
Eye Movements Facial Sensation and Motor Response Pharyngeal (Gag) Reflex Tracheal (Cough) Reflex

Pupils dilated with no constriction to bright light

Occulo-Cephalic Response

Dolls Eyes Maneuver

Oculo-Vestibular Response Cold Caloric Testing

Corneal Reflex

Jaw Reflex Grimace to Supraorbital or Temporo-Mandibular Pressure

Prerequisites
Core Body Temperature > 32 C Systolic Blood Pressure 90 mm Hg Normal Electrolytes Normal PCO2

1. Pre-Oxygenation
100% Oxygen via Tracheal Cannula PO2 = 200 mm Hg

2. Monitor PCO2 and PO2 with pulse oximetry 3. Disconnect Ventilator 4. Observe for Respiratory Movement until PCO2 = 60 mm Hg 5. Discontinue Testing if BP < 90, PO2 saturation decreases, or cardiac dysrhythmia observed

Facial Trauma
Pupillary Abnormalities CNS Sedatives or Neuromuscular Blockers Hepatic Failure Pulmonary Disease

EE G

Normal

Electrocerebral Silence

Cerebral Angiography

Normal

No Intracranial Flow

Technetium-99 Isotope Brain Scan

MR- Angiography

Transcranial Ultrasonography

Somatosensory Evoked Potentials