Condition that Mimic Brain

Death
Hypothermia
a state in which the body's mechanism for
temperature regulation is overwhelmed in the
face of a cold stressor
inadequate shelter for a homeless person,
someone caught in a winter storm or motor vehicle
accident
In the emergency department, core temperature
is best measured using a low-reading
temperature probe in the bladder or rectum or
an esophageal probe.
Mild (32-35), moderate (28-32), severe (<28)

The response to light is lost at core
temperatures of 28C to 32C, and brain-stem
reflexes disappear when the core temperature
drops below 28C.
These deficits are all potentially reversible,
even after extreme hypothermia.
The diagnosis of brain death cannot be
reliably made until the core temperature has
reached 32C. (It has led to the dictum "a
patient is not dead until the patient is warm
and dead.")

Approach:
Rewarm the patient with heating blanket or:
If no perfusing cardiac rhythm is present,
rewarming through cardiopulmonary bypass
Neurologic examination can only be done when
the core temperature reach 32 degree celcius.
Locked-In Syndrome (LIS)
a condition in which a patient is aware and
awake but cannot move or communicate
verbally due to complete paralysis of nearly all
voluntary muscles in the body except for the
eyes (extra-ocular muscle)
Mute (lack coordination of breathing and
voice) and motionless
Sometimes able to perceive sensory and
proprioception
Lesion in the ventral pons- affect motor
pathway (corticospinal tract) but not reticular
formation (consciousness)
Infarction (basilar artery embolism)
Bleeds
Tumor
Central pontine myelinolysis

Akinetic mutism
Patient awake, but remain silent and
motionless (not paralyzed)
Eye movement pick up sound stimulus
Due to injury at frontal lobe, thalamus and
ablation of cingulate gyrus (tx of psychosis).
Can also be due to Creutzfeldt-Jakob Disease
Frontal release sign might present
Persistent Vegetative state
The vegetative state is a chronic or long-term condition
occur after widespread severe damage to cerebral
hemispheres.
Patients in a vegetative state may have awoken from a
coma, but still have not regained awareness. In the
vegetative state patients can open their eyelids
occasionally and demonstrate sleep-wake cycles, but
completely lack cognitive function.
Differ from a coma, state that lacks both awareness
and wakefulness.
Persistent: more than one month
Psychogenic Unresponsiveness
Either due to schizophrenic somatoform
disorders or malingering
Patient often responds to painful stimuli
Normal vitals signs and neurological findings
Resists eye opening, fast to close them (interfere
corneal and pupillary reflex)
Dropped hand avoids hitting face
Nystagmus on caloric testing , normal EEG
Movements if present not stereotyped and
staged, but coordinated and purposive
Drug and Substances
The effects of many sedative and anesthetic
agents can closely mimic brain death, but
aspects of brain-stem function, particularly
the pupillary responses to light, remain intact.
Seen in reported in cases of intoxication with
tricyclic antidepressants and barbiturates.
Screening tests for drugs may be helpful, but
some toxins (e.g., cyanide, lithium, and
fentanyl) may not be detected by routine
screening tests.

Metabolic disturbances
Severe metabolic disturbances such as:
severe electrolyte imbalances,
hyper or hypoglycemia,
severe pH disturbances,
severe hepatic dysfunction or
renal dysfunction
can cause reversible coma and interfere with the clinical
evaluation of brain death.
These conditions should be identified and treated
before evaluation of brain death.

Organ Donation
Organ donation
Process of a person donating their organs for
transplant. These are given to someone with
2 types of donation:
Cadaveric donation
Donation after brain death
Donation after cardiac death
Living donation (family member) damaged organs
that need to be replaced.
What Organ can be Donated?
Two kidney : save four lives; two who receives the kidney
and two more because now they have a place at the
dialysis centre that has been vacated by the two who just
received a kidney transplant.
Heart, lung and liver : three or four more will get a chance
to live longer.
Eye : save two blind men with a damaged cornea.
Bone : can improve up to 20-30 lives of patients who need
a bone graft transfer.
Skin : is not life saving but it is a life altering moment. It will
be used to replace the damaged skin from burnt patients.
It helps with the healing and minimizes the risk of
infections.
Declaration of brain death
Consent from family for potential organ
donor
The federal authorities of transplantation unit should be
informed
Lab test - what is still functioning, can be transferred
and free from HIV, Hepatitis and Syphilis
Organ harvesting
3-8 hours
depending on no.
of tissue and organ
to be donated
Corpse be returned to the family
All surgery cut will be sewn carefully and
perfectly.
Cotton balls will be placed in the eye
brackets and it will be sewn just like a normal
eye surgery.
For bone donation, a fake bone will be
replaced in return of the donated bone so
there will be no physical deformation can be
seen
Turn of ventilation
machine
After lab test results
out and surgery can
be carried out
How to persuade bereaved family on
cadaveric donor?
1. Call the family or the next-of-kin to a quiet place/room.
2. Tell them about the patients condition, treatment and the
prognosis. Give time to them to accept the news. Explain and
inform them if have further questioning.
3. Make sure that family demonstrates understanding of
patients prognosis and brain death before any mention of
donation.
4. Once the family understand and accept the news, donation
presentation can be proceed (what is their thought, what is
organ donor, how it was done, the benefits of organ donor to
help living people)

Address the reasons why family against
donation (deceaseds wish, dispel any myth
about organ donation, act and religiousview)
It is important for the family to understand
that the deceaseds body will not be disfigured
and that donation will not affect funeral
arrangements or viewing of the body.
Give time to the family to make decision.
Respect their choice.
Legislation and Ethic
Human Tissue Act 1974
This act allows using body parts of the dead for
medical, education and medical research purposes.
Requires discussion and approval from the next of kin.
Malaysia Practices Opting-in Type Law
This allows a retrieval of organs from someone after
death if;
The deceased has made a written or verbal statement to
donate his organ after death when he was still alive
Approved by the deceased family or next of kin

Reference
DeJong's The Neurologic Examination