1. Coma, irreversible
and cause known
2. Neuroimaging explains coma (or is consistent
with the cause of coma)
3. CNS depressant drug effect absent (if
indicated toxicology screen; if barbiturates given, serum level ≤ 10 mcg/mL)
4. No evidence of neuromuscular blockade (per peripheral nerve electrical stimulator)
5. Absence of severe acid‐base, electrolyte,
endocrine abnormality
6. Normothermia or mild hypothermia (core
temperature ≥36°C)
7. Systolic blood pressure ≥100 mm Hg
8. No spontaneous respirations
Examination (all must be checked)
1. Absence of motor response to noxious stimuli
in all 4 limbs (spinally mediated reflexes are permissible)
2. Pupils nonreactive to bright light
3. Corneal reflex absent
4. Oculocephalic reflex (“Doll Eyes”) absent
(tested only if C‐spine integrity ensured)
5. Oculovestibular reflex (“Cold calorics”) absent
6. No facial movement to noxious stimuli at
supraorbital nerve, temporomandibular joint
7. Gag reflex absent
8. Cough reflex absent to tracheal suctioning
Apnea
testing (all must be
checked)
·
Patient is
hemodynamically stable before and throughout testing
·
Ventilator
adjusted to provide normocarbia (PaCO2 34–45 mm Hg)
·
Patient well‐oxygenated
with a PEEP of 5 cm of water
·
Prior to starting the test provide
oxygen via a suction catheter to the level of the carina at 6 L/min or attach T
piece with CPAP at 10 cm H2O
o
Disconnect
ventilator
o
Spontaneous
respirations absent
o
Arterial
blood gas drawn at 8–10 minutes or at termination of test, patient reconnected
to ventilator
o
PCO2 60 mm
Hg, or 20 mm Hg rise from normal baseline value
OR:
Apnea test
aborted
Ancillary
testing
Order
only if clinical examination cannot be fully performed due to patient factors, or
if apnea testing is inconclusive or aborted. Only 1 ancillary test needs to be
performed.
1. Cerebral angiogram
2. HMPAO SPECT (i.e., nuclear medicine cerebral
flow study.)
3. TCD
