Brain Death Determination
Standards for death by neurologic criteria in adults ≥18 at AHS.
Updated: 06/25/2025
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⚖️Legal Standard
▼- California Health & Safety Code §7180: death by neurologic criteria = irreversible cessation of all functions of the entire brain, including the brain stem
- §7181: requires independent confirmation by a second licensed physician
ℹ️
Two separate clinical examinations are required, one team preferably neurosurgery or neurology. Time of death is the completion of the second exam.
📋Prerequisites
▼- Irreversible and proximate cause established
- Drug screen: levels below therapeutic / 5× half-life cleared
- Blood alcohol <legal driving limit · no NMB agents
- No severe electrolyte/metabolic/endocrine disturbances
- Core temp ≥36°C · SBP ≥100 mmHg
- Labs: ABG, CBC, BMP, Osmolality, TSH/T4
💨Apnea Test Steps
▼1
Vasopressors → SBP ≥100
2
Preoxygenate ×10 min 100% O₂ → PaO₂ >200
3
Target PaCO₂ 35–45 · PEEP → 5 · SpO₂ >95% → baseline ABG
4
Disconnect vent — O₂ 6L/min via catheter to carina
5
Observe 8–10 min. Repeat ABG.
Positive: No respirations AND PaCO₂ ≥60 OR ≥20 mmHg rise. Abort if SBP <90 or SpO₂ <85% >30 sec.
ℹ️
Residents may perform exam only with attending directly supervising and attesting in all documentation.
🔦Brain Stem Reflexes — Technique
▼1
Pupils
Mid-size or larger (4–9 mm) and non-reactive to bright light. Confirm with pupillometry.
2
Oculocephalic
No eye movement with brisk head rotation.
3
Cold caloric
Head elevated 30°. Irrigate the external auditory canal with ~50 mL ice water over 1 minute; no eye movement. Wait 5 minutes before testing the other side.
4
Corneal
No eyelid movement when the cornea is touched with a cotton swab.
5
Facial
No grimace to supraorbital, temporomandibular, or mastoid pressure.
6
Pharyngeal / tracheal
No gag to tongue blade or suction; no cough on endotracheal suctioning to the level of the carina.
ℹ️
No spontaneous movement or response to noxious stimuli; no decorticate/decerebrate posturing, myoclonus, or seizures. Spinal reflexes do not exclude brain death.
⏳Reasonable Accommodation Period
▼- After the initial exam, the family has up to 24 hours
- During this period no sedating drugs may be given and the patient's physiology should be maximally supported
🧪Ancillary Testing
▼- Use when there is uncertainty about part of the neurologic exam, or when the apnea test cannot be performed
- Acceptable: nuclear medicine cerebral blood flow study (SPECT) or cerebral angiography
- These confirm absent cerebral blood flow — they are not substitutes for the clinical determination
📝Documentation & Organ Donation
▼- Each exam and apnea test must be documented and attested by an attending physician
- Prerequisites for the determination must be included in the documentation
🚫
No member of the patient care team should ever discuss organ donation with the family. If asked, say another team handles donation and will contact the family at the appropriate time.
- Status
- AHS Official Protocol
- Source
- sites.google.com/view/hghtrauma/brain-death-exam
- Last reviewed / updated
- 06/25/2025