- Neurosurgical
- Brainstem Death Testing
- Conditions
- Pathology identifiable and irreversible
- Unresponsive patient and not due to sedatives, hypothermia or potentially reversible circulatory, endocrine or metabolic disturbances.
- Patient apnoeic and not due to NMBDs
- Patient's time of death is at the time of the first set of tests
- Tests
- Pupils fixed with no direct or consensual reflexes (II, III)
- No corneal reflex (V, VII)
- No limb response to supraorbital pressure (V, III)
- Vestibulo-ocular reflexes absent on caloric testing. Check the TM first for wax. Head is flexed to 30 degrees & 50ml of iced water is used (VIII, III)
- No gag reflex (IX)
- No cough or other reflex with carina stimulation (X)
- Apnoea testing - no respiratory movements during apnoea. Patient should be ventilated with 100% prior, and the pCO₂ rise to 6.0 before disconnection. The pCO₂ is allowed to rise to 6.65 kPa confirmed by ABG.
- Head injury
- Normotension. Single episode of SBP <90mmHg has adverse outcome. Maintain CPP 70mmHg
- Normoxia - 4 fold increase in mortality is SpO₂ <60 at any point
- Normocapnoea - in the 24 hrs after HI the CBF is half normal and may be worsened by hypocapnoea
- Normothermia
- Normoglycaemia
- Management of raised ICP
- Medical
- Positioning
- Ties around neck loosened
- Sedation & NMBDs
- Ventilation and normocapnoea
- Osmotherapy to serum osmolality of 300-310 mosm/kg
- Temperature control and induced hypothermia
- Seizure control
- Surgical
- CSF drainage
- Craniectomy
- Lobectomy
- SAH classification
- World Federation of Neurosurgeons
Grade 1: GCS 15, no FND
Grade 2: GCS 13-14, no FND
Grade 3: GCS 13-14, focal neurology
Grade 4: GCS 7-12, +/- FND
Grade 5: GCS <7 +/- FND - Hunt and Hess classification
- Fisher score (radiological)