The document discusses guidelines for determining brain death in children. It outlines the criteria, including: 1) excluding reversible causes of coma through clinical examination and testing, 2) confirming absence of brainstem reflexes and apnea through a clinical examination and apnea test, and 3) declaring death after two examinations show findings consistent with brain death. Special considerations for newborns are discussed, as the diagnosis in this age group is more uncertain. Ancillary tests may be used but are not required to determine brain death.

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INTRODUCTION-
• In general Brain death is diagnosed if there is
irreversible loss of consciousness, absence of
brainstem reflexes, and apnea
• In 1987, guidelines for the determination of brain
death in children were published by a multisociety
task force.
• They emphasized the importance of the history and
clinical examination in determining the etiology of
coma so that correctable or reversible conditions were
eliminated.

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INTRODUCTION-
• Additionally, age-related observation periods and the
need for specific neurodiagnostic tests were
recommended for children 1 yr of age.
• Several inherent weaknesses have been recognized
including: 1) limited clinical information at the time of
publication,
2) uncertainty concerning the sensitivity and specificity of
ancillary testing,
3) biologic rationale for the use of age-based criteria,
4) little direction as to whether, when, and how the
diagnosis in neonates.

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VARIOUS CONCEPTS

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1) Exclusion of reversible causes of
coma
• Such as CNS depressant Drug intoxications,
including barbiturates, opioids, sedatives, intravenous
and inhalation anesthetics, antiepileptic agents, and
alcohols, muscle relaxants etc
• Metabolic disorders- severe metabolic disturbances
capable of causing a potentially reversible coma,
including electrolyte/glucose abnormalities
• Hypothermia- A core body temperature of 35°C
(95°F) should be achieved and maintained during
examination and testing to determine death.

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• Shock or persistent hypotension based on normal
values for the patient’s age.
• Systolic blood pressure or MAP should be in an
acceptable range (systolic blood pressure not 2 SDS
below age-appropriate norm) based on age

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Criteria For all practical purposes-
• Three steps involved are- 2) Ensuring the
preconditions have been met
• The patient should be in apneic coma
Objectively Coma- The patient must exhibit complete
loss of consciousness, vocalization, and volitional
activity.
Must lack all evidence of responsiveness.
Eye opening or eye movement to noxious
stimuli is absent.

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APNEA TEST-

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APNEA TEST-
Prior to test, prexygenation 100% for 5-10 min.
off IMV, under cardiac monitoring objectively
If no respiratory effort is observed from the
initiation of the apnea test to the time the
measured Paco2 60 mm Hg and 20 mm Hg
above the baseline level, the apnea test is
consistent with brain death.

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2) Confirmation of absent brainstem
reflexes and apnea-
Midposition or fully dilated pupils
which do not respond to light.
Absence of pupillary response to a
bright light in both eyes( Usually
pupils are fixed in midsize or dilated
position 4-9 mm)
Deep pressure on the condyles at the level
of the temporomandibular joints and deep
pressure at the supraorbital ridge should
produce no grimacing or facial muscle
movement

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• Absent gag, cough, sucking, and rooting reflex.
• The pharyngeal or gag reflex is tested after
stimulation of the posterior pharynx with a tongue
blade or suction device.
• The tracheal reflex- tested by examining the cough
response to tracheal suctioning. The catheter should
be inserted into the trachea and advanced to the
level of the carina followed by one or two suctioning
passes.

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• Absent corneal reflexes.- demonstrated by touching
the cornea with a piece of tissue paper, a cotton
swab, or squirts of water. No eyelid movement
should be seen.
• Absent oculovestibular reflexes- tested by irrigating
each ear with ice water (caloric testing) after the
patency of the external auditory canal is confirmed.
The head is elevated to 30°. Each external auditory
canal is irrigated (one ear at a time) with
approximately 10–50 mL of ice water.
• Movement of the eyes should be absent during 1
min of observation. Both sides are tested with an
interval of several minutes.

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OTHER TESTS OF IMPORTANCE-
• Oculocephalic reflex(doll’s eye)-
Procedure- Manually rotate the patient's head
side to side and closely watch the position of
the eyes.
Should not be performed in a patient with a cervical spine injury
Observation- In an intact patient, the eyes remain fixed
on a distant spot, as if maintaining eye contact with
that spot. In a result consistent with brain death, the
eyes move in concert with the patient's head
movement.

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• Some complex spinal movements may be particularly
pronounced following removal of the ventilator
• The best-known series of movements is the Lazarus
sign, which consists of extension of the upper
extremities followed by flexion of the arms with the
hands reaching to midsternal level. Flexion of the body
at the waist may occur. A variety of other movements
has been reported
Alert the family about….

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Ancillary studies-
• The committee recommends that ancillary studies are
not required to establish brain death and should not be
viewed as a substitute for the neurologic examination
• They include electroencephalography and
radionuclide cerebral blood flow
• Four-vessel intracranial contrast angiography has
previously been used as the definitive confirmatory
test, but practical technical difficulties and risks have
led to the use of nuclear medicine scans

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The role of ancillary studies-
Ancillary studies may be used 1) when components of
the examination or apnea testing cannot be completed
safely because of the underlying medical condition
2) if there is uncertainty about the results of the
neurologic examination
3) if a medication effect may be present or
4) to reduce the inter examination observation period

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Special considerations in newborns-
• Preterm and term neonates 7 days of age were
excluded from the 1987 Task Force guidelines.
• Diagnosis is uncertain because of the small number
of braindead neonates reported in the literature and
whether there are intrinsic biologic differences in
neonatal brain metabolism, bloodflow, and response
to injury.
• The newborn has patent sutures and an open
fontanelle resulting in less dramatic increases in
intracranial pressure after acute brain injury when
compared with older patients.

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Special considerations in neonates-
• The cascade of events associated with increased
intracranial pressure and reduced cerebral perfusion
ultimately leading to herniation is less likely to occur in
the neonate
• Ancillary studies performed in the newborn 30 days of
age are limited to ECS(electrocerebral silence) and
measuring CBF
• Both these are less sensitive than in older children
• CBF is comparatively more sensitive than measuring
electrical activity in diagnosing death

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DEATH DECLERATION-
a. Death is declared after
confirmation and completion
of the second clinical
examination and apnea test.
b. When ancillary studies
are used, documentation of
components from the
second clinical examination
that can be completed must
remain consistent with brain
death.

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All aspects of the clinical
examination, including
the apnea test, or ancillary
studies must be appropriately
documented.
c. The clinical examination
should be carried out by
qualified clinicians include
pediatric intensivists and
neonatologists, pediatric
neurologists and neurosurgeons;
and pediatric trauma surgeons
and pediatric anesthesiologists
with critical care training

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1987 2011
Waiting period before initial
brain death examination
Not specified 24 hrs after cardiopulmonary
resuscitation or severe
acute brain injury is suggested
if there are
concerns about the neurologic
examination or
if dictated by clinical judgment
Clinical examination Required required
Core body temperature Not specified 35°C (95°F)
Number of examinations Two examination;
second examination not
necessary in 2months to
1 yr age group if initial
examination,EEG and
concomitant cerebral
blood flow consistent
with brain death
Two examinations irrespective
of ancillary study
results (if ancillary testing is
being done in lieu of initial
examination elements that
cannot be
safely performed, the
components of the second
examination that can be done
must be
completed)

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Number of examiners Not specified Two (different attending
physicians must perform
the first and second exam
Observation interval
between neurologic
examinations
Age-dependent
7 days to 2 months: 48 hrs
2 months to 1 yr: 24 hrs
1 yr: 12 hrs (24 hrs if HIE)
Age-dependent
Term newborn (37 wks
gestation) to 30 days of
age: 24 hrs
31 days to 18 yrs: 12 hrs
Reduction of observation
period between
examinations
Permitted only for 1 yr age
group if EEG or cerebral
blood flow consistent with
brain death
Permitted for both age
groups if
EEG or cerebral blood flow
consistent with brain death
Apnea testing Required, number of tests
ambiguous
Two apnea tests required
unless clinically
contraindicated
Final pCO2 threshold for
apnea testing
Not specified 60 mm Hg and 20 mm Hg
above the baseline

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Ancillary study
recommended
Age-dependent
7 days to 2 months: 2
EEGs separated by
48 hrs
2 months to 1 yr: 2
EEGs separated by 24
hrs; cerebral blood flow
can replace the need for
second EEG
1 yr: no testing required
Not required except in
cases in which the
clinical examination and
apnea test cannot be
Completed Term
newborn (37 wks
gestation) to 30 days of
Age: EEG or cerebral
blood flow are less
sensitive in this age
group; cerebral blood
flow may be preferred
30 days to 18 yrs: EEG
and cerebral blood flow
have equal sensitivity
Time of death Not specified Time of the second
examination and apnea
test (or completion of
ancillary study and the
components of the second
examination that can be
safely completed)

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SUBMERSION INJURY

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Previous questions-
1. Near drowning in children
2. An 18 month old child was brought to you after he
fell upside down in a tub filled with water. Briefly
describe the possible injuries and preventive
strategies to avoid similar situation in future.
3. Describe the pathogenetic mechanism of injury in
near drowning. Discuss the steps of initial
resuscitation and subsequent hospital management.
4. Discuss the pathophysiology of submersion injury. A
4 year old boy was rescued 10 min back from a
pond and rushed to the hospital emergency.
Mention the basic principles of management.

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epidemiology in relation to age-

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Pathophysiology-
conscious person initially panics, trying to surface, small
amounts of water enter the hypopharynx, triggering
laryngospasm.
Progressive desaturation and the person soon loses
consciousness from hypoxia.
Profound hypoxia and medullary depression lead to terminal
apnea
By 3-4 min, the circulation abruptly fails because of myocardial
hypoxia Ineffective cardiac contractions with electrical activity
may occur briefly
Some drowning victims have a primary cardiac arrest secondary
to a variant of an inherited prolonged QT syndrome.

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COMPLICATIONS-
BRAIN CNS injury is the most common cause of
mortality and long-term morbidity.
Duration of anoxia associated with
irreversible damage is probably on the
order of 3-5 min.
cerebral edema may occur, although the
mechanism is not entirely clear.
Severe cerebral edema can elevate
intracranial pressure (ICP), contributing to
further ischemia; and intracranial hypertension
is an ominous sign

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Complications-

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COMPLICATIONS-

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HYPOTHERMIA-
• According to core body temperature, mild (34-36 C),
moderate (30-34 C), or severe (<30 C)
• Heat loss occurs both during and after the drowning
• Heat loss is mainly through conduction and
convection
• Children are at increased risk for hypothermia
because they have a relatively high ratio of body
surface area to mass, decreased subcutaneous fat,
and limited thermogenic capacity.

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HYPOTHERMIA- EFFECTS
CVS
CNS
Most often hypothermia is a poor
prognostic sign, and a neuroprotective
effect has not been demonstrated. But
theoretically it is possible for the brain to
rapidly cool to a neuroprotective level until
hemodynamically unstable, apnoea
With moderate to severe hypothermia,
progressive bradycardia, impaired
myocardial contractility, and loss of
vasomotor tone contribute to inadequate
perfusion, hypotension, and possible shock.
At body temperature <28 C, extreme
bradycardia, ventricular fibrillation (VF) or
asystole can occur.

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Hypothermia-
• Victims who drown in water <60-70 F also experience
cold water shock, a dynamic series of
cardiorespiratory physiologic responses.
• In human adults, immersion in icy water results in
intense involuntary reflex hyperventilation and to a
decrease in breath-holding ability to <10 seconds,
which leads to fluid aspiration, contributing to more
rapid and deep hypothermia. Severe bradycardia
occurs in adults but is transient and rapidly followed by
supraventricular and ectopic tachycardias and
hypertension.

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MANAGEMENT-
• INITIAL EVALUATION AND RESUSCITATION-
Immediate CPR at the event site.
• The goal is to reverse the anoxia from submersion and
prevent secondary hypoxic injury after submersion.
• When safe, institution of in-water resuscitation for
nonbreathing victims by trained personnel may
improve the likelihood of survival.
• Initial resuscitation must focus on rapidly restoring
oxygenation, ventilation, and adequate circulation

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MANAGEMENT-
• The airway should be clear of vomitus and foreign
material, which may cause obstruction or aspiration.
• Abdominal thrusts should not be used for fluid
removal because of chances of regurgitation and
aspiration.
• In cases of suspected airway foreign body, chest
compressions or back blows are preferable
maneuvers

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MANAGEMENT-
• The cervical spine should be protected in anyone with
potential traumatic neck injury
• Breathing- If the pt. is apneic, begin ventilation with
positive pressure bag and mask with 100% inspired
oxygen
• If apnea, cyanosis, hypoventilation, or labored
respiration persists, trained personnel should perform
endotracheal tube (ET) intubation as soon as possible

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Management-
• Circulation- CPR should be instituted immediately in
pulseless, bradycardic, or severely hypotensive
victims.
• Continuously monitor the ECG and treat arrhythmias.
• Identify shock .
• Recognition and treatment of hypothermia are the
unique aspects of cardiac resuscitation in the
drowning victim.
• IV fluids and cardioactive medications are required to
improve circulation and perfusion

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DETECTION OF CT FINDING-
• Early CT findings within 48 hours- range from normal
to diffuse cerebral edema
• Later CT reveal diffuse loss of gray-white
differentiation with a uniform ground glass appearance
of entire brain , indicating severe, global HIE process
• Other finding include reversal sign- decreased signals
in the supratentorial compartment with relatve
increase in density of the basal ganglia and brainstem
• Abnormal cranial CT poor prognosis

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At the arrival at the ER-

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In the PICU-

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HYPOTHERMIA SALIENT POINTS-
• (1) controlled hypothermia, such as that used in the
operating room before the onset of hypoxia or
ischemia,
• (2) accidental hypothermia, such as occurs in
drowning, which is uncontrolled and variable, with
onset during or shortly after hypoxia-ischemia, and
• (3) therapeutic hypothermia, involving the purposeful
and controlled lowering and maintenance of body (or
brain) temperature at some time after a hypoxic-
ischemic event.

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•THANK YOU

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