Thread by @rkchoi

There is so much confusion on what #braindeath is and what it is not (see

https://twitter.com/EricLawson90/status/1563204028539908098?s=20&t=Ao2zaC55J8mvcztaJfBoiQ

or dailymemphian.com/subscriber/sec…) that I wanted to provide some education on this critically important matter. A 🧵 on its history and more #neurotwitter #medtwitter
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Before mechanical ventilation, death was defined as the cessation of circulation and breathing, and even though it seemed straight forward, a true phobia in the 18th and 19th C was that of being buried alive. Hence #safetycoffins from where the term #savedbythebell is derived:
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In 1959, Mollaret and Goulon describe #comadepasee or "overcoma" where 23 people had no movement, no EEG activity, polyuria and required pressors, and would quickly die if pressors were stopped: pubmed.ncbi.nlm.nih.gov/14423403/ and was also described by Wertheimer/Jouvet the same year
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In 1963 a Belgian surgeon introduces the term #braindeath for a patient with severe brain injury but a heart beat, and procures the person's kidney, at the time considered morally questionable
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In 1968, an Ad Hoc Committee of Harvard Medical School publishes “A definition of Irreversible Coma” in the journal of the American Medical Association: jamanetwork.com/journals/jama/…
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Features include:
1⃣Unreceptivity and unresponsitivity - no unawareness to external stimuli and unresponsiveness to painful stimuli
2⃣No movements or breathing—no muscular movement, spontaneous respiration or response to stimuli
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3⃣No reflexes—fixed, dilated pupils; lack of eye movement even when turned, or ice water is placed in the ear
4⃣Lack of response to noxious stimuli
They also recommend a flat EEG and to exclude confounders such as hypothermia or drug intoxication
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In the 80's, the Presidential Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research issued a report in 1981, Defining Death: Medical, Legal and Ethical Issues in the Determination of Death: scholarworks.iupui.edu/bitstream/hand…
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This becomes the basis for the UDDA which reads: “An individual who has sustained either:
irreversible cessation of circulatory and respiratory functions, OR irreversible cessation of all functions of the entire brain, including the brain stem, is dead.”
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The UDDA becomes the model for individual state laws governing the determination of death and is then applied in all 50 states. According to the UDDA, an individual who has sustained an irreversible cessation of whole brain function, including the brain stem, is dead.
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For #braindeath determination:
1⃣ Find a cause: Clinical or neuroimaging evidence of a central nervous system catastrophe that is compatible with the diagnosis of brain death
2⃣Injury must be IRREVERSIBLE
Allow sufficient time to exclude the possibility of reversibility
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3⃣Rule out confounders: Patient is not hypotensive, hypothermic, paralyzed, intoxication, hypoxia, etc.
4⃣Unresponsiveness is documented: Patient not locked-in, no response or spontaneous movements to pain
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We ✅ all of the following:
Brainstem:
Pupillary reactivity to light
Corneal reflex
Oculocephalic (Doll’s Eye) reflex
Cold calorics reflex
Jaw-jerk reflex
Cough and gag response
Other:
Facial grimacing or other response to painful stimuli other than reflexes
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We then conduct an #apneatest and observe for respirations with the patient off the ventilator (usually). CO2 levels are monitored in the medulla and absence of a respiratory drive despite markedly elevated C02 levels signifies medullary failure.
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If the CO2 level is >60 or >20 from the baseline at the end of the test and we have not observed respiratory effort, the test is consistent with #braindeath
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Confirmatory testing is sometimes completed if we cannot complete a portion of the bedside testing or if confounding factors cannot be ruled out. These tests include:
4-Vessel Angiogram
Cerebral Blood Flow (CBF) Study
EEG
Transcranial Dopplers
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#braindeath is NOT:
- Coma-An unconscious state
- Vegetative State (PVS) / Unresponsive Wakefulness Syndrome (UWS)-A wakeful unconscious state
- Minimally Conscious State (MCS) - minimal but definite behavioral evidence of awareness
- Locked-in Syndrome - due to pontine dz
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#braindeath is also NOT:
- partial death
- feeling tired

But it IS:
Death

When someone is pronounced brain dead, they are being pronounced dead
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There is still much confusion in the media and in the public's understanding of brain death.
#braindeath is not something that healthcare providers take lightly. I take each declaration very seriously, and it is critical that we get it right. Each. And. Every. Time.
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More resources:
emcrit.org/ibcc/brain-dea…
jamanetwork.com/journals/jama/…
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Also, be aware the UDDA is being revised. Read pubmed.ncbi.nlm.nih.gov/35102538/
for more info
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So in conclusion, #braindeath is:
✅due to a catastrophic brain injury leading to permanent cessation of all brain and brainstem activity
✅the same as death - time of brain death declaration = time of death
✅taken very seriously by those of us who declare it
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Because of its importance and because we must be certain these criteria is met, the @neurocritical ethics committee will also be working on a set of educational guidelines and standards and @neurocritical has already created a brain death course:
neurocriticalcare.org/education/brai…
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#braindeath should not be controversial. The process of declaration should be completed absolutely and without wavering. While other organs may be replaceable (ie., via transplant), it is the 🧠 that contains who we are. When it dies, we die.
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Other thoughts? @caseyalbin @EricLawson90 @neurocritical @ShadiYaghi2 @JayKinariwala @CajalButterfly @Capt_Ammonia @DrAtulRamesh1 @RamaniBalu1 @DSandsmarkMDPhD @oneDRwoman1 @PulmCrit