Brain Death New Guidelines

 RNs/MDs from CC Medicine, Sections on CC/Neuro from the AAP, Child Neurology Society. Work resulted in 2011 publication of clinical report
updating the guidelines for determining pediatric brain death in infants and children
 Reduction in time interval between exams for all age groups

Guidelines for Determine Brain Death

 History: Clinical diagnosis based on the absence of neurological function with a known irreversible cause of coma
 Prerequisites to examination
 > 24 hrs after insult
 Correct hypotension, hypothermia, and metabolic disorders
 Stop sedative agents, analgesic agents, neuromuscular blocking agents, and anticonvulsants
 Examination Findings Observation
 Examination findings must remain consistent with brain death during the entire observation period
 37-week neonates up to 30 days of age
 Two examinations performed 24 hours apart by different attending physicians
 >30 days to 18 years of age
 Two examinations performed 12 hours apart by different attending physicians

Physical examination elements of Brain Death

 Flaccid tone and absence of spontaneous or induced movements, excluding spinal cord reflexes
 Coma
 Absence of brain stem function
 Mid position or fully dilated pupils
 Absence of bulbar musculature, corneal, gag, cough, sucking, and rooting reflexes
 Absent oculovestibular reflexes

Absent Brain stem reflexes What Cranial nerve?

 Fixed pupils (CN II & III): unresponsive to bright light
 Absent corneal reflexes (CN V & VII): touching edge of cornea w swab and no response noted
 Absent oculocephalic reflex (CN III, IV,VI) - doll’s eyes: no movement w rapid turning of head
 Absent oculovestibular reflex : cold caloric (CN III, VI, & VIII)
 Absent gag and cough (CN, VII, IX )
 Apnea X

Basic exam 3 Eye movement

 Oculocephalic reflex = doll’s eyes
 Normal response is movement of eyes when head is turned
 Oculovestibular reflex = cold caloric test
 Movement of eyes intact reflex

Other Tests
 Apnea testing
 Arterial Pa co 2 must rise 20 mm Hg above the patient’s baseline and 60 mm Hg with no respiratory effort
 contraindications to testing include high cervical spine injuries, high oxygen requirements, or high ventilator settings.
 Brain Imaging and other tests
 Not required unless elements of the clinical examination or apnea testing cannot be completed
 May not substitute for the neurological examination
 Can be used to reduce the observation period

Ancillary Studies
 Four vessel cerebral angiography is the gold standard for determining the absence of CBF
 EEG & radionuclide CBF are the most widely used methods
 Cerebral blood flow = perfusion scan

Organ donation
 Call regional transplant coordinator for all deaths
 Donor or not in your eyes
 Tissue – bone, corneas, heart valves
 Do not mention organ donation to family
 “Gift of life” will approach them after the child is declared
 If family asks you about donation
 Acknowledge that it is a wonderful gift they are considering
 Tell them you will contact “Gift of life” to have them available for questions

Head Trauma and ICP Monitoring Physical Exam Findings

• Neuro:
 Chief Complaint and HPI
• TR is a 4 month old male, who presents via EMS following being found unresponsive in the crib
• Was in usual state of good health this morning when Mom left him for work in the care of her boyfriend
• Per BF, placed in crib to sleep at 1000, at 1045 noted limp/blue w poor pulse. CPR started, EMS called
• On arrival, EMS intubated TR, and gave 1 dose of Epi before ROSC
Past Medical History
• TR was born at 38 weeks gestational age via C-section due to breech positioning
• He was discharged home on DOL 2 with his mother
• He has been growing well and meeting all developmental milestones
• Immunizations are up to date
• He is formula feed and takes no medications
• little more fussy than usual previous 2 d, but has no other signs of illness
Family Hx and Psycoscocial
• TR lives at home with Mom and her boyfriend (not his father)
• His father is involved and has custody every other weekend

ICP Monitors
• External Ventricular Drain
 Can be used to drain CSF as well as monitor ICP
 Drain is leveled based on a set pressure, over which CSF will be drained What labs and testing should we do?
 ICP values are not always accurate when the EVD is open to drain • CBC, CMP, Coags
• Bolt ICP Monitor • ABG
 Does not drain, only monitors • Chest X-ray
 Provides a more accurate monitoring of ICPs • CT of the head: : large, subdural hematoma
 Less risk of bleeding, infection and dislodgement compared to EVD in right parietal region w small midline shift
 neurosurgery decided to take
Management Plan emergently to OR for evacuation of
• TR went to the PICU post-operatively with an ICP bolt bleed and placement of ICP Monitor
• Followed the Society of Pediatric Critical Care Medicine recommendations regarding ICP Management What is on list of differentials at this point?
 HOB elevated • Non-accidental Trauma
 Maintain CPP >45 via Norepinephrine infusion • SIDs
 Required neuromuscular blockade and a continuous infusion of 3% NSS to keep ICP <15 • Infectious Cause
• Ophthalmology consulted to look for retinal hemorrhages • New onset seizures
 Exam positive for bilateral retinal hemorrhages, consistent with non-accidental trauma • Undiagnosed Cardiac Defect
• Neurology consulted regarding prophylactic seizure management
 Started on Keppra BID

Progression of Hospital Course

• MRI D2, showed diffuse anoxic BI w signs of cerebral edema; D3, rapidly increasing ICPs despite all strategies used.
• Pupils became unequal, then progressed to be fixed an dilated; GCS decreased to 3
• Period of progressive HTN w assoc bradycardia and ICP, followed by rapid BP w normalization of HR and ICP, consistent w herniation

Brain Death Testing Summary

• All reversible cause of coma must be removed—normothermic/tensive, no sedatives/toxins, or electrolyte abnor that may impact neuro function
• 2 separate exams must be completed by two different attending physicians
 Infants less than 30 days must be completed 24 hours apart
 Greater than 30 days exams can be 12 hours apart
• Must have an absence of brainstem reflexes
• No spontaneous respirations despite a CO2 >60

Organ Donation
• Organ procurement organization should be called anytime you are concerned for brain death/planning on doing testing
• Most OPOs request that they be the first to talk to the family about donations.
• If the decision is made to donate, coordination between the OPO and the PICU team to maintain organ viability prior to procurement
 Typically need frequent lab tests, x-rays, ECHO and liver/renal ultrasounds to determine organ viability
 All costs for tests/medications involved in the work up for donation are covered by the OPO, the patient’s family is not responsible
 Maintain tight control of hemodynamics, oxygenation, and electrolytes
 Process from decision to donate until procurement can take 24-48 hours

Head Injury Teaching/Follow Up Prevention is key!

• Wear a seat belt in the car; Wear a helmet on bikes/ATVs/while skinning/snowboarding/skating
• Use baby gates to prevent falls down stairs in infants and toddlers; Do not leave unattended on couch/chair/bed they can roll off of
• Period of purple crying in babies
 Between 2 weeks and 4 months, most babies will experience a period of persistent crying
 P-peak of crying, U-unexpected, R-resistant to soothing, P-pain like face, L-long lasting, E-worse in the evening
 It is ok to put the baby down in a safe place (like the crib) and let them cry when parents become overwhelmed.
 Make smart choices regarding who babysits the child
Neurosurgery: Causes and treatments for Increased ICP CSF Flow
Hydrocephalus: Major cause of increase ICPs “Water on the brain” • Lateral ventricles
• Mismatch btwn CSF prod and absorp leading to abnormal buildup of CSF/ICP • Foramen of Monroe
• Ventriculomegaly • Third ventricle
 Enlargement of the ventricles • Cerebral Aqueduct
 Communicating (non-obstructive): • Fourth ventricle
 Blockage outside ventricles. • Out foramen of Luschka + Magendie around SC
 CSF still flow btwn ventricles, which remain open. • Back up around convexities + absorbed into venous sinus system
 Non-Communicating
 Blockage within the ventricles
 1 most common cause "aqueductal stenosis." hydrocephalus froma narrowing of aqueduct of Sylvius, a small passage between the 3rd and
4th ventricles in middle of brain
• CSF produced in large part (50-80%) by choroid plexus. Produced from ventricles; about 500ml/day

Other causes that lead to increased ICPs

• Subdural: hemorrhagic intracerebral contusion into subdural space. Dura intact
 LOC, severe cerebral edema, seizures, midline shift, Cushings reflex, herniation
 Treatments:
 Emergent ventriculostomy or ICP monitor.
 Surgical intervention for evacuation or shunt
• Arachnoid cysts: CSF covered by arachnoid cells and collagen develop btwn surface of brain and cranial base or on arachnoid membrane-(1/3
membranes cover brain/SC; cong disorder and most begin during infancy; onset may be delayed until adolescence and usually need no tx
Classic S &S of ICP (Normal Level 0-10)
Infants: usually non- specific Children
irritability headache
poor feeding vomiting especially upon rising in am
lethargy blurred vision/ eye move abnorm
HC, large AF altered mental status
vomiting papilledema
classic sunset appearance of eyes gait disturbances
Cushing's Triad (ICP, BP, HR) Cushing’s Triad

Treatment and Monitoring

• External ventricular device (EVD)
• ICP Monitors
 Ventriculostomy: Drain excess fluid (usually CSF- to lower ICPs) and monitor ICP
 Placement: In the ventricle, subdural or epidural space
 Advantages are relative low cost, option for therapeutic drainage, ability to recalibrate
 Disadvantages: difficulty w insertion on pt w decompressed ventricles, need to maintain transducer at fixed reference point relative to pt,
not accurate read when open to drain, risks of infection
 Intraparenchymal monitor (Not a Treatment)
 Advantages are its ease of insertion especially in patients with decreased ventricles, more accurate monitoring of ICPs.
 Disadvantages include inability to recalibrate to zero after they have been inserted into skull and experience measurement drift overtime.

What to know
• Tragus is the part of the ear that drainage system is zeroed
• When order is for 10 above tragus: This means CSF will drain when ICP is above 10. (# is variable based upon Neurosurgical order)
• 2 stopcocks between collection buterol and patient

EVD Placement
• Tragus:
• Levels:
 The higher the placement above the tragus the slower the drainage
 The lower the placement from the tragus the faster the csf is removed
 Complications for draining to fast- subdural hematomas because it ruptures the vessels along the subarachnoid space
• ICP monitoring
 Intra-parenchymal (Bolt)
 Only used to monitor pressure: Is not an intervention

Medical management
• Goal is to keep the ICPs low:
 Mannitol
 3% Sodium Chloride
• Temporary treatment for intracranial hypertension
 Diamox= not during acute emergencies
 Dexamethasone
 Zantac/Pepcid