A 64-year-old man is found unresponsive, pulseless, and with asystole when the ambulance arrives. He is intubated, resuscitated, and transferred to the hospital. Initial workup is consistent with subarachnoid bleeding. The patient has a history of coronary artery disease, multiple percutaneous coronary interventions, and congestive heart failure with low left ventricular ejection fraction. On repeat evaluation 24 hours later, he is comatose and does not respond to any verbal stimuli. The patient's temperature is 36.7 C (98.1 F), blood pressure is 123/82 mm Hg, and pulse is 78/min. Pupils are dilated and fixed at 8 mm. Which of the following findings would most likely suggest brain death in this patient?

Question

A 64-year-old man is found unresponsive, pulseless, and with asystole when the ambulance arrives.  He is intubated, resuscitated, and transferred to the hospital.  Initial workup is consistent with subarachnoid bleeding.  The patient has a history of coronary artery disease, multiple percutaneous coronary interventions, and congestive heart failure with low left ventricular ejection fraction.  On repeat evaluation 24 hours later, he is comatose and does not respond to any verbal stimuli.  The patient's temperature is 36.7 C (98.1 F), blood pressure is 123/82 mm Hg, and pulse is 78/min.  Pupils are dilated and fixed at 8 mm.  Which of the following findings would most likely suggest brain death in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c188_5312_8f63_291b106b82ef_MD0005_00 Brain death is the irreversible absence of cerebral and brain stem function. Clinical criteria suggestive of brain death include clinical or brain imaging evidence of a devastating cause, absence of confounding factors (eg, major endocrine or electrolyte disturbances, drug intoxication), and hemodynamic stability (core body temperature >36 C [96.8 F], systolic blood pressure >100 mm Hg). Neurologic examination typically shows irreversible absence of cerebral and brainstem reflexes including pupillary, oculocephalic, oculovestibular (caloric), corneal, gag, sucking, swallowing, and extensor posturing. This patient is comatose with no response to verbal stimuli and an absent pupillary reflex, all consistent with brain death. An absent cough reflex on tracheal suctioning is also highly suggestive of brain death. (Choices B, C, D, and E) Patients with brain death can have spontaneous movements, but these originate from peripheral nerves or the spinal cord. Possible reflexes include finger flexion, truncal movements (eg, superficial and deep abdominal muscles), triple flexion response (flexion at the hip, knee, and ankle with foot stimulation), plantar reflexes (Babinski sign), limb movements to painful stimuli, and alternating flexion-extension of the toes. Educational objective: Patients with brain death have absence of reflexes associated with cortical and brainstem function (pupillary, oculocephalic, oculovestibular [caloric], corneal, gag, sucking, swallowing, and extensor posturing). Patients with brain death can have reflexes and movements, but these originate from peripheral nerves or the spinal cord. References: Diagnosis of brain death. (http://www.ncbi.nlm.nih.gov/pubmed/21577338)

A 64-Year-Old Man Is Found Unresponsive, Pulseless, and with Asystole