Makindo Medical Notes.com

There are regional differences but the general principles are the same. Need to assess for at least 2 mins.

About

• Death is a process involving the cessation of physiological functions. The determination of death is the final event in that process. For most people, death takes occurs with the confirmation of irreversible cessation of cardiorespiratory function.
• For others a more detailed assessment is needed especially in the realms of ITU and ventilators. Being on a Ventilator does not necessarily mean life.
• Although there are different ways to determine death, there is only one way of being dead; thus, the two classic algorithms of brain death and circulatory death initially presented should merge into a single endpoint identified as death and should not imply that brain death and circulatory death are two distinct phenomena

Confirming Death in the normal manner

• Wash your hands, identify the patient. Pull the ward screens around. Take your time. Be sensitive as a family may be present at the time of death. You may wish them to leave but that is your decision. As long as they are quiet and do not interrupt you can perform the assessment.
• Check over a 5-minute period (observation of breathing and auscultation can happen together)
  • (1) Palpate absence of a carotid or femoral pulse on palpation and
  • (2) Listen for the absence of heart sound on auscultation
  • (3) Observe the absence of breathing and respiratory effort
  • (4) Look for the absence of pupillary responses to light. Pupils usually fixed and dilated
• The time of death is recorded as the time at which these criteria are fulfilled. Document your findings. Date, time and GMC number. Speak to the family as appropriate. Offer condolences. Answer any queries. Most issues will be managed by the bereavement office.

The algorithm should then state that one or more of the following instrumental tests should be performed if indicated:

• (1) asystole or pulseless electrical activity on a continuous ECG display; and/or
• (2) absence of pulsatile flow during intraarterial pressure monitoring; and/or
• (3) absence of contractile activity using echocardiography.
• Instrumental tests are not mandatory since diagnosis can be made without them. The instrumental tests would, however, be indicated for patients on advanced life support therapies or for whom life-sustaining treatment is withdrawn in a critical care setting.

Brain Death: Coma + absent brainstem reflexes + apnoea

• Brain death: brainstem function lost (no spontaneous ventilation)
• Death: Irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brainstem.
• Aetiology of coma known from clinical assessment or neuroimaging or catastrophic structural damage to the CNS

Diagnostic criteria of brain death

• Confirm clearance of depressant drugs: Exclude toxic levels of sedatives, aminoglycosides, tricyclic antidepressants, anticholinergics, antiepileptic drugs, chemotherapeutic agents, neuromuscular blockade
• Absence of hypothermia: (defined as temperature <32 C)
• No gross electrolyte/acid-base/metabolic issues e.g. hypothyroid, liver failure
• Apnoea: absence of relaxants, opioids or other depressants. Raised PaCO₂, normal PaO₂
• Irreversible structure brain damage

Procedure

• No Pupillary response to light
• Corneal reflex absent
• Vestibulo-ocular reflexes absent
• Caloric tests 20 ml ice-cold water in ear canals, no eye movement
• Facial motor response to trigeminal distribution pain absent
• Gag and cough reflexes absent
• Apnoea in the presence of PaCO₂ >60 mmHg, pH < 7.30
• Two examinations at least 2 h apart by separate qualified doctors usually registrar grade or above
• Angiography required if no diagnosis or tests incomplete (e.g. eye injury)
• Modified criteria <1 year of age due to greater recovery potential

References

• A CODE OF PRACTICE FOR THE DIAGNOSIS AND CONFIRMATION OF DEATH AMRC UK
• Clinical Criteria for the Determination of Death WHO Technical Expert Consultation

Revisions