In this hot case, the examiners invite the candidate to confirm or dispute the diagnosis of brain death.
To remind you, brain death is...
The patient must also satisfy the pre-conditions for testing:
The candidate must assure themselves of the above features, and then go on to examine the brain stem reflexes.
Previous hot cases with this sort of theme to them can be found below.
The standard introduction
Ask examiners about turning up the lights
The physical examination
The details of this section can be seen in the opposite column.
The obs and investigations
The Physical Examination in Brief Detail
Ask the examiners to sit the patient up
Ask the examiners about any language barriers
Ask examiners to lay the patient flat.
A pacing box?
Sensitivity and pacing threshold may not be relevant.
One can ask the examiners the following questions:
One should ask about the following parameters:
One should ask to look at the pressure-volume loops.
The key feature here is triggering. One must ask the examiners whether the patient has been observed to trigger the ventilator, and what the trigger settings are.
There may be surgical drains (what is in them? How much of it?). Asking how much has been coming out may not be relevant in a hot case which focuses on the diagnosis of brain death.
The pleural catheters are also interesting. One should make a mental note of whether the ICCs are on free drainage or on suction. The content of these drains could be informative, especially if one notices blood or chyle. A bronchopleural fistula attached to a wall suction drain may produce enough flow to trigger the ventilator, and produce the false impression of respiratory effort.
A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:
The patient you are examining may be actively cooled. Ask about the target temperature; again, normothermia is required to determine brain death.
This stage is critically important. The drug and fluid infusions which are currently in progress give a clue as to what problem is currently being addressed. One should not neglect the labelled bags; the choice of antibiotics gives one some idea of where the source of sepsis is thought to be.
Any sedation or neuromuscular blockade should be mentioned to the examiners as a disqualifying feature. Additionally, one may wish to ask them about the most recent doses of paralysing or sedating agents, keeping in mind the possibility that clearance mechanisms are not working at 100%.
One should observe the following features of an EVD:
Intracranial pressure should be asked about, if it is not immediately obvious.
Ideally, one should get the patient sitting up to 30-45°. This may not be possible. However, one should still ask for it.
Ideally, the patient should be exposed from the waist up. The candidate can then stand back and look for anything externally obvious:
Performing the GCS: you must ascertain that there is "unresponsive coma".
One should spent a second assessing whether the hands are warm or cold.
One can over-focus on the nails, but this focused examination is aimed to confirm or dispute the diagnosis of brain death, and the nails play a rather peripheral role in that.
Still, one ought to try to compare the radial pulses.
Tone of the upper limbs
Move up from the hands. While you are still holding the hands, you can perform a sort of gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows.
The brain-dead patient may have increased tone.
Examine the cubital fossa for
This part of the examination focuses on clinical brain death testing.
It occurs in a sequence:
Ask the examiners to dim the room lights.
Open both eyes. Each eye is exposed to light. The opposite pupil should constrict consensually.
This tests CN II (afferent) and CN III (efferent).
The cornea (not the sclera) is touched lightly with a moistened corner of a piece of gauze.
A normal reflex is to blink.
This tests CN V (afferent) and CN VII (efferent)
Typically, this is performed by putting some pressure on the superior orbital notch.The patient should either open their eyes or localise. This tests CN V.
This test is an extension of the testing for unresponsive coma; with painful stimulus in the cranial nerve distribution, confusing spinal reflexes will not occur.
In the comatose patient, as the head is moved from left to right, the eyes should move in the opposite direction. A fixed unchanging gaze is a negative test; the reflex is not working.
This tests CNs III, IV, VI, and most importantly VIII.
Cold water is funneled into the patient's ear. A positive reflex consists of the eyes turning towards the chilled ear. This is a more potent stimulus for CN VIII than the oculocephalic reflex.
The Yankeur sucker is used to probe the posterior pharynx, on both sides. A gag reaction should result from this.
This collectively tests CN X and IX.
While on the subject of CN X, one may test the cough reflex by suctioning the trachea.
This tests CN X.
This is also a convenient time to ask about the volume and character of the secretions.
With the cranial nerve reflexes negative, one may move on to apnoea testing.
One should ask the examiners whether this is permitted.
More than likely, one will instead be asked to describe how one would go about it.
With this established, one may go on to perform a brief examination of the remaining organ systems, to satisfy one's curiosity regarding the viability of the rest of the organ systems.
One puts both their hands on the chest to assess the symmetry of chest expansion.
One might wish to percuss the chest. If this is done in a slick fashion, it can be forgiven.
Changes in percussion resonance may be worth commenting on.
One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases.
The clever candidate will make a big show of palpating both the apex and the right sternal edge.
One should auscultate in the following sequence:
The various clicks and murmurs one encounters are discussed elsewhere.
For this, one should ask to lay the patient flat.
The pelvic content would have been palpated during the abdominal examination.
The more important part of this examination is the groin.
At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.
Observation and palpation of the pelvis:
Examination of the lines
Examination of the genitals and rectum
Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.
One should ask to remove TEDs and compression stockings.
Ask to see the obs chart. If it is not allowed, ask for the following:
One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO
One needs to show an interest in the following labs:
One should always ask for the following:
You sometimes want to see the following:
One is looking for confirmation of some sort of "irreversible" brain-injuring pathology.
"Mr Bloggs is braindead."
"I have come to this conclusion on the basis of the following findings: [regurgitate the conditions here]"
"I would like to convey my diagnosis to the family and the primary team."
"I would also like to explore the wishes of the deceased and their family regarding organ donation"
"Mr Bloggs is not braindead."
"I have come to this conclusion on the basis of the following findings: [list the unmet preconditions or failed tests]"
"I would like to perform the following investigations in order to explore the possility of locked-in syndrome: [list of investigations - typically MRI, EEG]"
"Furthermore, I would like to enlist the help of the neurology service in order to explore the possible diagnosis of akinetic mutism or persisting vegetative state."
"I am unable to determine whether Mr Bloggs is braindead."
"The following features render the conventional brain death testing invalid [list the unmet preconditions]"
"I would like to perform the following investigations in order to confirm the absence of intracranial blood flow: [list of investigations - typically Tc99-HMPAO scan, 4-vessel angio, transcranial doppler, EEG and so forth]"