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DRAFT - Pending Review

This plan requires physician review before clinical use.

Brain Death Evaluation / Death by Neurologic Criteria (DNC)

VERSION: 1.1 CREATED: January 30, 2026 REVISED: January 30, 2026 STATUS: Draft - Pending Review

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DIAGNOSIS: Brain Death / Death by Neurologic Criteria (DNC)

ICD-10: G93.82 (Brain death), G93.1 (Anoxic brain damage, not elsewhere classified), G93.5 (Compression of brain), G93.6 (Cerebral edema), T85.110A (Breakdown of ventricular intracranial shunt, initial encounter), S06.9X (Unspecified intracranial injury)

SYNONYMS: Brain death, death by neurologic criteria, DNC, brain stem death, irreversible coma, whole brain death, neurological death, cerebral death, brain death determination, brain death testing, brain death evaluation, brain death protocol, brain death exam, BD evaluation, BD determination, BD testing, neurologic determination of death, NDD

SCOPE: Comprehensive evaluation and determination of brain death (death by neurologic criteria) in adults per AAN 2023 updated practice guideline. Covers prerequisites for testing, clinical examination (coma and brainstem reflex testing), apnea test protocol, ancillary testing indications and options, documentation requirements, family communication, legal/ethical considerations, organ procurement organization (OPO) notification, and donor management protocols. Excludes pediatric brain death determination (different age-specific criteria per AAP/CNS/SCCM guidelines), determination in neonates, and determination in patients on ECMO (requires institutional-specific protocols).

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KEY DEFINITIONS:

• Brain Death / Death by Neurologic Criteria (DNC): Irreversible cessation of all functions of the entire brain, including the brainstem (Uniform Determination of Death Act, 1981)
• Clinical Examination: Assessment of coma (absence of consciousness) and brainstem areflexia (absence of all brainstem reflexes)
• Apnea Test: Confirmatory test for absence of respiratory drive from the brainstem
• Ancillary Test: Supplementary diagnostic test used when clinical examination or apnea test cannot be completed, or when confounders cannot be excluded
• Confounder: Any condition that may mimic brain death findings and must be excluded before proceeding with determination

CRITICAL FRAMEWORK:

Brain death determination is a clinical diagnosis. The clinical examination (including apnea testing) is the gold standard. Ancillary tests are supplementary and used only when clinical testing is incomplete or confounders cannot be excluded.

LEGAL NOTE: Brain death determination requirements vary by state and institution. Clinicians must be familiar with local laws, institutional policies, and specific requirements regarding:

• Number of examinations required (1 vs. 2)
• Time interval between examinations
• Qualifications of examining physicians
• Mandatory ancillary testing requirements
• Religious/conscientious objection accommodations (e.g., New Jersey)

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP

1A. Essential/Core Labs (Prerequisites — Must Be Obtained BEFORE Brain Death Examination)

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Core body temperature (CPT 99000)	PREREQUISITE: Hypothermia must be excluded as confounder; core temp ≥36°C (96.8°F) required before examination	Core temperature ≥36°C (96.8°F); if hypothermic, actively rewarm before proceeding	STAT	STAT	-	STAT
CMP (BMP + LFTs) (CPT 80053)	PREREQUISITE: Exclude severe metabolic derangement as confounder; electrolytes, glucose, renal and hepatic function	No severe metabolic derangement: sodium 115-160 mEq/L; glucose >54 mg/dL; no hepatic encephalopathy; no severe uremia	STAT	STAT	-	STAT
Blood glucose (CPT 82947)	PREREQUISITE: Hypoglycemia can mimic brain death; must be excluded	Glucose >54 mg/dL (>3 mmol/L); if low, correct and reassess	STAT	STAT	-	STAT
Arterial blood gas (ABG) (CPT 82803)	PREREQUISITE: Baseline before apnea test; assess acid-base status; ensure adequate pre-oxygenation; confirm PaCO2 baseline	Pre-apnea test baseline: PaCO2 35-45 mmHg; pH 7.35-7.45; PaO2 >200 mmHg (after pre-oxygenation); post-apnea: PaCO2 ≥60 mmHg AND ≥20 mmHg above baseline	STAT	STAT	-	STAT
Serum osmolality (CPT 83930)	Exclude hyperosmolar state as confounder; assess for severe dehydration	<320 mOsm/kg; severe hyperosmolality may confound examination	STAT	STAT	-	STAT
Comprehensive toxicology screen (CPT 80307)	PREREQUISITE: Exclude CNS depressant drug intoxication as confounder; sedatives, narcotics, paralytics, barbiturates, alcohol	Negative for CNS depressants; if positive, must wait for clearance (5 half-lives) or use ancillary testing	STAT	STAT	-	STAT
Serum drug levels (specific)	If any CNS depressant administered: measure specific drug levels; barbiturate, benzodiazepine, opioid, propofol levels	Below therapeutic/active levels; barbiturates <10 mcg/mL; midazolam <50 ng/mL; propofol: discontinued ≥5 half-lives	STAT	STAT	-	STAT
CBC with differential (CPT 85025)	Baseline; infection assessment; evaluate for sepsis as potential confounder; organ donation workup	Normal or interpretable in context; severe sepsis/septic shock may confound	STAT	STAT	-	STAT
PT/INR (CPT 85610), aPTT (CPT 85730)	Baseline coagulation; organ donation workup; procedural planning	Normal or correctable; coagulopathy does not preclude brain death testing	STAT	STAT	-	STAT
Lactate (CPT 83605)	Assess tissue perfusion; hemodynamic adequacy for valid examination	<4 mmol/L preferred; severe shock must be treated before valid examination	STAT	STAT	-	STAT
Type and screen (CPT 86900)	Organ donation preparedness; potential surgical procedures	On file	STAT	STAT	-	STAT
Thyroid function (TSH, free T4) (CPT 84443, 84439)	Exclude severe hypothyroidism (myxedema coma) as confounder; donor management (hormone replacement therapy protocol)	TSH and free T4 within range that excludes myxedema; if severely abnormal, correct or use ancillary testing	STAT	STAT	-	STAT
Cortisol (random) (CPT 82533)	Donor management protocol (assess adrenal function); severe adrenal insufficiency as confounder (rare)	>10 mcg/dL (random); if low, initiate stress-dose steroids for donor management	STAT	STAT	-	STAT

1B. Extended Workup (Serial / Monitoring / Organ Donation Workup)

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Serial ABG (pre- and post-apnea test)	CRITICAL for apnea test: Pre-test baseline PaCO2 → post-test PaCO2 must rise ≥60 mmHg AND ≥20 mmHg above baseline	Pre-test: PaCO2 35-45 mmHg; PaO2 >200 after pre-oxygenation; Post-test: PaCO2 ≥60 AND ≥20 above baseline = positive (absent respiratory drive)	STAT	STAT	-	STAT
Serial sodium (q4-6h)	Diabetes insipidus is common in brain death (posterior pituitary failure); rapidly rising sodium indicates DI	Watch for rapid sodium rise >145 mEq/L; rising >2-3 mEq/L/hr suggests diabetes insipidus; initiate desmopressin	-	STAT	-	STAT
Urine output monitoring (hourly)	Diabetes insipidus detection; polyuria >250-300 mL/hr or >3 mL/kg/hr with dilute urine indicates DI	<200 mL/hr; if >300 mL/hr with serum Na rising and urine specific gravity <1.005 → DI; treat with desmopressin	-	STAT	-	STAT
Urine specific gravity / urine osmolality	Confirm diabetes insipidus if polyuria present; dilute urine with rising serum sodium	Urine specific gravity >1.005; if <1.005 with polyuria and hypernatremia → DI confirmed	-	STAT	-	STAT
Troponin (CPT 84484)	Neurogenic cardiac injury assessment; organ donation cardiac evaluation	Normal or mildly elevated acceptable; severely elevated → echocardiography for donation evaluation	STAT	STAT	-	STAT
BNP/NT-proBNP (CPT 83880)	Cardiac function assessment for donation	Normal or mildly elevated; guides cardiac donation suitability	-	STAT	-	STAT
Procalcitonin (CPT 84145)	Infection evaluation; organ donation infectious disease screening	<0.5 ng/mL preferred; elevated → evaluate for infection source; does not preclude donation	-	STAT	-	STAT
Blood cultures x2 sets (CPT 87040)	Organ donation infectious disease screening; evaluate for sepsis	No growth; if positive → treat and evaluate donation eligibility per OPO protocols	STAT	STAT	-	STAT
Urinalysis and urine culture (CPT 81001, 87088)	Organ donation screening; infection assessment	Negative; if UTI → treat; does not preclude donation	STAT	STAT	-	STAT
HIV, Hepatitis B surface Ag, Hepatitis B core Ab, Hepatitis C Ab (CPT 86689, 87340, 86704, 86803)	Required for organ donation: Infectious disease screening per UNOS requirements	Negative preferred; positive results do not absolutely preclude donation (NAT testing; risk-assessed donors)	-	STAT	-	STAT
CMV IgG, EBV IgG (CPT 86644, 86663)	Organ donation viral serology; recipient matching	Document serostatus for recipient matching	-	STAT	-	STAT
HbA1c (CPT 83036)	Organ donation; pancreas/kidney suitability assessment	<6.5% preferred for pancreas donation; elevated → may preclude pancreas but not other organs	-	ROUTINE	-	ROUTINE
Lipase (CPT 83690)	Pancreas donation suitability	Normal; elevated → evaluate pancreas suitability for donation	-	ROUTINE	-	ROUTINE

1C. Rare/Specialized

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Quantitative drug levels (barbiturate, benzodiazepine, propofol metabolite)	When specific CNS depressant clearance must be confirmed; if standard toxicology screen insufficient	Below threshold that could confound examination: pentobarbital <10 mcg/mL; phenobarbital <10 mcg/mL; midazolam <50 ng/mL	STAT	STAT	-	STAT
Anti-GQ1b antibodies	If Guillain-Barre (Miller Fisher variant) suspected as mimic; areflexia with ophthalmoplegia	Negative; if positive → GBS mimic, NOT brain death; requires alternative evaluation	-	EXT	-	EXT
Serum ammonia (CPT 82140)	Exclude severe hepatic encephalopathy as confounder	<200 μmol/L; severely elevated ammonia (>200) may confound clinical exam; treat hepatic failure first	STAT	STAT	-	STAT
Neuromuscular junction testing (train-of-four)	PREREQUISITE if neuromuscular blocking agents administered: Must confirm 4/4 twitches (complete recovery from paralysis) before clinical examination	4 of 4 twitches present (full neuromuscular recovery); if <4/4, examination is invalid — wait for clearance or use ancillary test	STAT	STAT	-	STAT

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line (Establish Etiology — PREREQUISITE)

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
CT head without contrast (CPT 70450)	PREREQUISITE — Must establish known structural cause of brain death; imaging before examination	Identified catastrophic brain injury: massive stroke, hemorrhage, anoxic injury (diffuse edema, loss of gray-white differentiation), herniation, absence of intracranial blood flow (dense MCA sign); must establish irreversible cause	None for non-contrast CT	STAT	STAT	-	STAT
CT angiography head (CTA) (CPT 70496)	If etiology unclear; may serve as ancillary test for cerebral circulatory arrest if performed per protocol	Absence of intracranial arterial opacification (if used as ancillary test); identifies vascular cause (massive stroke, SAH)	Contrast allergy (premedicate); renal impairment (acceptable if donation anticipated)	STAT	STAT	-	STAT

2B. Ancillary Tests (When Clinical Examination Cannot Be Completed)

INDICATIONS FOR ANCILLARY TESTING (AAN 2023):

• Clinical examination cannot be fully performed (e.g., severe facial/orbital trauma precluding pupil or corneal testing)
• Apnea test cannot be completed or is inconclusive (e.g., hemodynamic instability, severe ARDS with baseline hypercarbia)
• Confounders cannot be resolved (e.g., CNS depressant drugs cannot be cleared in timely fashion, hypothermia refractory to rewarming)
• Institutional policy requires ancillary testing
• To shorten observation period between examinations (if allowed by institutional policy)

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
Cerebral angiography (4-vessel conventional) (CPT 36224-36226)	Gold standard ancillary test; when clinical testing cannot be completed	Absence of intracerebral filling at the level of the carotid bifurcation or circle of Willis; external carotid filling may be present; delayed filling up to the proximal segments does NOT exclude brain death if no intracerebral filling	Contrast allergy; hemodynamic instability (relative — may require vasopressor support during procedure); renal impairment (acceptable if donation anticipated)	-	STAT	-	STAT
Technetium-99m HMPAO SPECT brain perfusion scan (CPT 78607)	Radionuclide cerebral perfusion study; widely available; high sensitivity and specificity	"Hollow skull" phenomenon: Complete absence of intracranial tracer uptake; no perfusion to cerebral hemispheres or brainstem; scalp and facial blood flow present (external carotid territory)	None absolute; limited availability of isotope in some centers; patient must be transported to nuclear medicine (logistically challenging for unstable patients)	-	STAT	-	STAT
Technetium-99m pertechnetate cerebral blood flow study (CPT 78610)	Alternative radionuclide study; more widely available than HMPAO	Absence of intracranial blood flow on anterior and lateral views; "empty light bulb" sign; less sensitive for posterior fossa/brainstem than HMPAO-SPECT	Same as above; pertechnetate less specific than HMPAO for posterior fossa	-	STAT	-	STAT
EEG (electrocerebral inactivity) (CPT 95816)	Demonstrates electrocerebral inactivity (ECI); 16+ channel recording per ACNS guidelines	Electrocerebral inactivity (ECI): No electrical activity >2 μV over 30 minutes of recording; must use minimum 16 channels; interelectrode distances ≥10 cm; impedances 100-10,000 ohms; sensitivity 2 μV/mm; high-frequency filter ≤70 Hz; low-frequency filter ≤1 Hz	Does NOT assess brainstem function directly; can be confounded by sedatives, hypothermia, metabolic derangement; artifact from ICU environment; should NOT be sole ancillary test if brainstem assessment incomplete	-	STAT	-	STAT
CT angiography (CTA) — brain death protocol (CPT 70496)	Non-invasive vascular study; increasingly used; AAN 2023 acknowledges but notes variable sensitivity	Absence of opacification of cortical segments of MCA, cortical segments of ACA, and internal cerebral veins (7-point CTA scoring system); some protocols assess 4-point or 10-point systems	Contrast allergy; renal impairment; false negatives possible (sensitivity 85-95% depending on protocol and timing of image acquisition)	-	STAT	-	STAT
Transcranial Doppler ultrasonography (TCD) (CPT 93886)	Non-invasive bedside study; can be repeated; useful for trending toward brain death	Cerebral circulatory arrest pattern: Reverberating (oscillating) flow pattern; small systolic spikes (<50 cm/s duration <200 ms); absent diastolic flow → absent flow in all assessed vessels; must assess bilateral MCA AND basilar artery	Operator-dependent; 10-15% of patients have inadequate temporal windows; not universally accepted as sole ancillary test; AAN 2023: acceptable if institutional protocol supports; cannot assess in presence of craniectomy defects	-	STAT	-	STAT

2C. Rare/Advanced Ancillary Tests

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI/MRA brain (CPT 70553)	Rarely used for brain death determination; may demonstrate diffuse injury; MRA may show absent flow	Diffuse cortical and brainstem injury; absent intracranial arterial flow on MRA; tonsillar herniation; diffuse restricted diffusion on DWI	MRI-incompatible devices; hemodynamic instability; transport risk; prolonged study time in unstable patient	-	EXT	-	EXT
Somatosensory evoked potentials (SSEP) (CPT 95925)	Assesses brainstem and cortical conduction; bilateral median nerve stimulation	Bilateral absence of N20 cortical response with preserved Erb point potential (peripheral nerve intact, cortex non-functional); does NOT assess brainstem directly	Peripheral neuropathy may confound; requires intact peripheral nerve; not widely available for acute bedside use	-	EXT	-	EXT
Brainstem auditory evoked potentials (BAEP) (CPT 92585)	Assesses auditory brainstem pathway; complements EEG (which only assesses cortex)	Absence of all waveforms beyond wave I (wave I may be present — cochlear origin; absence of waves III and V = brainstem non-function)	Middle ear pathology; peripheral hearing loss; limited availability	-	EXT	-	EXT

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3. TREATMENT PROTOCOLS

3A. Confounder Management (Prerequisites Before Brain Death Examination)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Active rewarming	External/Internal	Hypothermia correction; core temperature must be ≥36°C before examination	Target ≥36°C :: External/Internal :: continuous :: Warm IV fluids 40-42°C; forced air warming blankets; warmed humidified ventilator gases; if severe hypothermia: peritoneal lavage, bladder irrigation, or extracorporeal rewarming; must achieve target before proceeding	None; must achieve target before proceeding	Core temperature continuous monitoring (esophageal, rectal, or bladder probe); target ≥36°C	STAT	STAT	-	STAT
Desmopressin (DDAVP)	IV	Diabetes insipidus treatment (common in brain death due to pituitary failure); maintain hemodynamic stability for valid examination	1-4 mcg :: IV :: q6-12h PRN :: 1-4 mcg IV q6-12h; titrate to urine output <200-300 mL/hr; may also give 10-20 mcg intranasally; onset IV: 15-30 min; adjust based on urine output and sodium	Hyponatremia (relative)	Urine output hourly; serum sodium q2-4h; urine specific gravity; serum osmolality; goal UOP 0.5-3 mL/kg/hr	STAT	STAT	-	STAT
Isotonic crystalloid (0.9% NaCl or LR)	IV	Volume resuscitation for hemodynamic stability; replace massive urine losses from DI; maintain adequate perfusion for valid examination	0.9% NaCl :: IV :: continuous :: Bolus 500-1000 mL for hypotension; maintenance 100-250 mL/hr; replace urine output mL-for-mL if DI present; avoid hypotonic fluids	Fluid overload; pulmonary edema (balance with organ preservation goals)	CVP if available; urine output; serum sodium; blood pressure; lung auscultation	STAT	STAT	-	STAT
Norepinephrine	IV	Vasopressor for hemodynamic support; neurogenic shock (loss of sympathetic tone) common in brain death; maintain MAP ≥60 mmHg for valid examination	0.1-0.5 mcg/kg/min :: IV :: continuous :: Start 0.05-0.1 mcg/kg/min; titrate to MAP ≥60 mmHg (or ≥70 for donor management); max 0.5 mcg/kg/min; consider adding vasopressin if escalating	Peripheral extravasation (central line required)	Continuous arterial BP monitoring; MAP target ≥60; assess for adequate organ perfusion; limit escalation if possible for donor management	STAT	STAT	-	STAT
Vasopressin	IV	Adjunct vasopressor; particularly useful in brain death (endogenous vasopressin deficiency from pituitary failure); hemodynamic support + DI treatment	0.01-0.04 units/min :: IV :: continuous :: Start 0.01 units/min; titrate to MAP ≥60 mmHg; max 0.04 units/min for vasopressor effect; also treats DI at higher doses; AAN/HRSA donor management: 1 unit IV bolus then 0.5-2.4 units/hr	High-dose may cause mesenteric ischemia; coronary vasoconstriction	MAP continuous; urine output hourly; lactate; assess perfusion; cardiac telemetry	STAT	STAT	-	STAT
Correction of metabolic derangements	IV	Exclude metabolic confounders; sodium, glucose, pH, calcium must be within acceptable ranges	Per derangement :: IV :: PRN :: Correct sodium to 115-160 mEq/L range; glucose >54 mg/dL (D50 50 mL if needed); correct severe acidosis (NaHCO3 if pH <7.2); correct severe hypocalcemia (calcium gluconate 1-2 g IV); correct hypothyroidism	Overly rapid sodium correction (risk of osmotic demyelination — less relevant in brain death but important for organ preservation)	Serial electrolytes q2-4h; glucose q1-2h; ABG q4h; target physiologic ranges	STAT	STAT	-	STAT

3B. Apnea Test Protocol (Step-by-Step)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Step 1: Pre-oxygenation	Ventilator	Prevent hypoxia during apnea test; build oxygen reservoir	FiO2 1.0 :: Ventilator :: ≥10 min :: Pre-oxygenate with FiO2 1.0 (100% O2) for ≥10 minutes before disconnection; confirm PaO2 >200 mmHg on pre-apnea ABG	None	ABG after 10 min pre-oxygenation; SpO2 continuous; confirm PaO2 >200 mmHg	STAT	STAT	-	STAT
Step 2: Baseline ABG	Arterial	Establish PaCO2 baseline; must be 35-45 mmHg before starting apnea test	ABG draw :: Arterial :: once :: Draw ABG after pre-oxygenation; adjust ventilator to normalize PaCO2 if needed; if baseline PaCO2 chronically elevated (e.g., COPD), target must be ≥20 mmHg above chronic baseline AND ≥60 mmHg	If PaCO2 cannot be normalized to 35-45 (chronic hypercarbia), document chronic baseline and adjust targets accordingly	PaCO2 35-45 mmHg; pH 7.35-7.45; if chronically elevated CO2, document baseline	STAT	STAT	-	STAT
Step 3: Disconnect ventilator and apply O2	Intratracheal	Apnea test initiation; remove external respiratory drive; observe for spontaneous respiratory effort	6-10 L/min O2 :: Intratracheal :: continuous :: Disconnect from ventilator; immediately place O2 cannula into trachea (or T-piece with CPAP at 5-10 cmH2O) delivering 6-10 L/min O2 at carina level; ensures oxygenation without ventilation	Severe ARDS with FiO2 >0.7 and PEEP >10 (may desaturate rapidly — consider ancillary test instead); hemodynamic instability (relative)	SpO2 continuous; arterial line continuous; direct observation for ANY respiratory movement (chest, abdomen)	STAT	STAT	-	STAT
Step 4: Observe for respiratory effort	Visual	Detect any spontaneous breathing; absence confirms apnea	8-10 min :: Visual :: once :: Observe 8-10 minutes (AAN 2023); watch for ANY chest or abdominal respiratory movements; look at proximal ETT for condensation/gas movement; if ANY respiratory effort observed → ABORT: patient is NOT brain dead	SpO2 <85% despite O2 supplementation; severe hemodynamic instability (MAP <60 despite vasopressors); dangerous cardiac arrhythmia	Visual observation: chest wall, abdomen; SpO2; BP continuous; cardiac telemetry; 8-10 min observation minimum	STAT	STAT	-	STAT
Step 5: Post-apnea ABG	Arterial	Confirm PaCO2 rise meets threshold for valid test	ABG draw :: Arterial :: once :: Draw ABG at 8-10 minutes of apnea (or sooner if SpO2 <85%); POSITIVE (absent respiratory drive): PaCO2 ≥60 mmHg AND rise ≥20 mmHg above baseline	If PaCO2 target not reached and test aborted for desaturation, test is INCONCLUSIVE — need ancillary test	PaCO2 ≥60 mmHg AND ≥20 above baseline = POSITIVE (brain death); if target not met → repeat or ancillary test	STAT	STAT	-	STAT
Step 6: Reconnect ventilator	Ventilator	Resume mechanical ventilation after ABG drawn; restore hemodynamic stability	Pre-test settings :: Ventilator :: continuous :: Reconnect to pre-test ventilator settings immediately after post-apnea ABG drawn; restore FiO2 1.0 temporarily; resume standard settings once stable	None	SpO2; BP; cardiac rhythm; ensure hemodynamic stability; resume standard ventilator settings	STAT	STAT	-	STAT

3C. Donor Management Protocol (After Brain Death Declaration — Organ Preservation)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Vasopressin (donor management)	IV	Hemodynamic support and DI treatment; first-line vasopressor for brain-dead donors per UNOS/HRSA protocol	0.5-2.4 units/hr :: IV :: continuous :: HRSA protocol: 1 unit IV bolus then 0.5-2.4 units/hr; titrate to MAP ≥60 mmHg; also treats DI; preferred over catecholamines (less myocardial oxygen demand)	Mesenteric ischemia at high doses; coronary vasoconstriction	MAP continuous; urine output hourly; serum sodium q2-4h; lactate q6h; target MAP 60-100 mmHg; CVP 4-12 mmHg	-	STAT	-	STAT
Levothyroxine (T4)	IV	Hormone replacement therapy (HRT) for brain-dead donors; pituitary failure causes hypothyroidism; improves hemodynamic stability and organ function	20 mcg :: IV :: bolus then continuous :: HRSA protocol: 20 mcg IV bolus then 10 mcg/hr continuous infusion; alternative: T3 (liothyronine) 4 mcg IV bolus then 3 mcg/hr; improves cardiac output and donor hemodynamics	None in this context	TSH, free T4 q6-12h; hemodynamic response; cardiac function	-	STAT	-	STAT
Methylprednisolone	IV	Hormone replacement therapy component; reduces inflammation; supports hemodynamic stability; decreases vasopressor requirement; improves oxygenation	15 mg/kg :: IV :: once :: HRSA protocol: 15 mg/kg IV bolus (max 1 g); single dose; alternative: hydrocortisone 100 mg IV q8h or stress dose 50 mg q6h; reduces inflammatory cytokines; improves lung and cardiac donation outcomes	Active untreated infection (relative)	Blood glucose (hyperglycemia common); hemodynamic response; WBC (may be falsely elevated)	-	STAT	-	STAT
Insulin infusion	IV	Glycemic control during donor management; methylprednisolone and stress response cause hyperglycemia; tight glucose control improves organ preservation	1-10 units/hr :: IV :: continuous :: Regular insulin infusion; target blood glucose 120-180 mg/dL; start if BG >150 mg/dL; titrate per institutional insulin drip protocol; avoid hypoglycemia (<70 mg/dL)	Hypoglycemia; hypokalemia	Blood glucose q1-2h; potassium q4h; avoid hypoglycemia	-	STAT	-	STAT
Desmopressin (DDAVP) (donor management)	IV	Diabetes insipidus treatment; maintain euvolemia and sodium homeostasis for organ preservation; most brain-dead patients develop DI	1-4 mcg :: IV :: q6h PRN :: 1-4 mcg IV q6-12h PRN; titrate to urine output 0.5-3 mL/kg/hr; target sodium 135-155 mEq/L; may also give 10-20 mcg intranasally	Hyponatremia (hold if Na <135)	Urine output hourly; serum sodium q2-4h; urine specific gravity; goal UOP 0.5-3 mL/kg/hr; serum osmolality	-	STAT	-	STAT
Norepinephrine (donor management)	IV	Second-line vasopressor if vasopressin insufficient; maintain MAP ≥60 mmHg; minimize dose to reduce end-organ catecholamine toxicity	0.05-0.2 mcg/kg/min :: IV :: continuous :: Start 0.05 mcg/kg/min; titrate to MAP ≥60; goal: minimize catecholamine use (excess catecholamines damage transplantable organs, especially heart); transition to vasopressin-dominant regimen	Peripheral administration (central line required); excessive doses damage cardiac allografts	MAP; cardiac function; troponin trends; try to wean as vasopressin and HRT take effect	-	STAT	-	STAT
Mechanical ventilation (lung-protective for donation)	Ventilator	Maintain oxygenation; lung-protective ventilation preserves lungs for transplant	TV 6-8 mL/kg IBW :: Ventilator :: continuous :: Tidal volume 6-8 mL/kg IBW; PEEP 5-10 cmH2O; FiO2 titrate to SpO2 >95%; target PaO2 >100 mmHg; recruitment maneuvers PRN; suction PRN; avoid excessive tidal volumes	None	ABG q4-6h; SpO2 continuous; CXR daily; peak and plateau pressures; compliance trending	-	STAT	-	STAT
Goal-directed fluid therapy	IV	Euvolemia maintenance; organ perfusion; replace insensible and DI losses without fluid overload (damages lungs)	100-250 mL/hr :: IV :: continuous :: 0.9% NaCl or LR; titrate to CVP 4-12 mmHg (or PCWP 8-12 mmHg if PA catheter); avoid hypovolemia (organ ischemia) and hypervolemia (pulmonary edema); use balanced crystalloid; transfuse PRN (Hgb >7 g/dL)	Pulmonary edema (restrict fluids, add diuretics if lung preservation critical)	CVP; urine output; lactate; hemodynamics; daily CXR; ECHO if available	-	STAT	-	STAT

3D. Medications to AVOID During Brain Death Examination

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
All sedatives (propofol, midazolam, dexmedetomidine)	-	Must be discontinued ≥5 half-lives before clinical examination; active sedation invalidates brain death determination	-	Active sedation invalidates brain death examination	Drug levels if uncertain clearance; clinical assessment; ancillary testing if clearance uncertain	-	-	-	-
All opioids (fentanyl, morphine, hydromorphone)	-	Must be discontinued ≥5 half-lives before clinical examination; opioids suppress respiratory drive (invalidate apnea test)	-	Active opioids invalidate apnea test	Drug levels if uncertain clearance; naloxone reversal NOT sufficient (reversal may be incomplete; must confirm clearance)	-	-	-	-
Neuromuscular blocking agents (rocuronium, cisatracurium, vecuronium)	-	Must be fully reversed before clinical examination; paralysis prevents assessment of motor and respiratory function	-	Active paralysis completely invalidates all clinical brain death testing	Train-of-four monitoring: must show 4/4 twitches before examination; sugammadex reversal for rocuronium/vecuronium if needed; wait for spontaneous clearance of cisatracurium	-	-	-	-
Atropine (diagnostic test — should NOT be administered as treatment)	-	Atropine is used as a diagnostic test during brain death examination (IV bolus → no heart rate increase confirms vagal nucleus non-function); NOT a treatment	-	Not used therapeutically in this context; used diagnostically: 1 mg IV → if NO heart rate increase >3% → confirms brainstem non-function	Document pre- and post-atropine heart rate; absence of response supports brain death	-	-	-	-

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU	Details
Notify attending physician and neurology/neurocritical care for brain death evaluation when clinical suspicion arises	STAT	STAT	-	STAT	Brain death determination requires qualified physician(s); AAN 2023: physician with training in brain death evaluation; most states require attending-level physician; some require neurologist/neurosurgeon
Verify institutional brain death policy and state law requirements before proceeding	STAT	STAT	-	STAT	Requirements vary: number of examinations (1 vs. 2); interval between exams (varies: 6h, 12h, 24h, or no minimum per AAN 2023); qualifications of examiners; mandatory ancillary testing; documentation forms
Contact Organ Procurement Organization (OPO) — REQUIRED by federal law when brain death is imminent or declared	STAT	STAT	-	STAT	Federal requirement (CMS Conditions of Participation): Hospitals must notify OPO of all imminent deaths (GCS 5 or less, ventilator-dependent); OPO determines donation suitability; OPO coordinates family approach for consent; do NOT approach family about donation without OPO involvement
Establish time of death as time of completion of brain death determination (final examination or ancillary test)	-	STAT	-	STAT	Time of death = time of completed clinical examination (or ancillary test); NOT the time of cardiac arrest or ventilator withdrawal; document precisely on death certificate
Ensure at least one independent qualified examiner for brain death determination	STAT	STAT	-	STAT	AAN 2023: Physician must be credentialed in brain death determination; most states: attending physician; some require neurologist, neurosurgeon, or intensivist; examiner must not be part of transplant team
Document all prerequisites, clinical findings, and apnea test results on institutional brain death determination form	-	STAT	-	STAT	Use standardized checklist/form; document: etiology, confounders excluded, core temp, drug clearance, each brainstem reflex result, apnea test results with ABG values, time of determination, examiner signature

4B. Patient/Family Instructions

Recommendation	ED	HOSP	OPD	ICU	Details
Family meeting to explain prognosis, brain death concept, and planned evaluation process BEFORE beginning testing	URGENT	URGENT	-	URGENT	Use clear, direct language: "The brain has been severely and irreversibly damaged"; explain the difference between brain death and coma; avoid confusing terminology ("life support" when patient is dead); use interpreter services if needed
Provide family with explanation that brain death IS legal death in all 50 US states (with NJ religious exemption)	URGENT	URGENT	-	URGENT	Address common misconceptions: brain death ≠ coma, ≠ vegetative state, ≠ "pulling the plug"; the patient is dead; ventilator maintains organ function but the person has died; legal death with full legal death certificate
Social work and chaplain/spiritual care consultation for family support	URGENT	URGENT	-	URGENT	Grief counseling; cultural/religious sensitivity; some families need time to process (reasonable accommodation without indefinite ventilator use); address cultural differences in death acceptance; offer family presence during testing if appropriate per institutional policy
Palliative care consultation for family support and goals-of-care discussion if determination is delayed or contested	-	URGENT	-	URGENT	Particularly helpful when: family disputes brain death; religious objections (NJ exemption); cultural barriers; prolonged ICU course before determination; complex ethical situations
Communicate with OPO regarding family approach timing and strategy	-	STAT	-	STAT	OPO-trained requestors should approach family for organ donation; timing of approach (before or after declaration, per OPO protocol); physician should NOT be the one requesting organ donation (conflict of interest)
Provide family time with patient after brain death declaration and before organ recovery, if applicable	-	URGENT	-	URGENT	Allow family to say goodbye; arrange for religious/spiritual rituals if requested; coordinate with OPO for timing; if organ donation proceeding, ventilator continues until OR; if no donation, discuss timing of ventilator discontinuation

4C. Legal, Ethical & Documentation

Recommendation	ED	HOSP	OPD	ICU	Details
Complete institutional brain death determination checklist documenting all prerequisites and examination findings	-	STAT	-	STAT	Standardized documentation prevents legal challenges; include: etiology, confounders excluded (temp, drugs, metabolic), each brainstem reflex tested and result, apnea test results with ABG values, time of each examination, examiner credentials
Issue death certificate with time of death as moment of brain death declaration, NOT time of ventilator removal	-	STAT	-	STAT	Legal time of death = final brain death examination completion time; if two exams required, time of second exam; if ancillary test, time ancillary test interpreted; death certificate cause: underlying etiology (e.g., "Anoxic brain injury due to cardiac arrest")
Address religious/conscientious objections per state law (New Jersey Declaration of Death Act)	-	URGENT	-	URGENT	New Jersey: if family objects to brain death on religious grounds, physician must accommodate (patient remains legally alive on ventilator); no other state has this law; institutional ethics consultation recommended; reasonable accommodation in other states (varies by institution)
Ethics consultation if brain death determination is contested, delayed, or involves complex circumstances	-	URGENT	-	URGENT	Indications: family refuses to accept brain death; religious/cultural objections; medical uncertainty about confounders; disagreement between physicians; pregnant patient (may continue somatic support); medicolegal concerns

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═══════════════════════════════════════════════════════════════ SECTION B: SUPPORTING INFORMATION ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS

Conditions That May Mimic Brain Death (Must Be Excluded)

Condition	Key Distinguishing Features	Tests to Differentiate
Severe hypothermia (<32°C)	History of exposure; core temperature <32°C; can cause fixed dilated pupils, absent reflexes, flat EEG; FULLY REVERSIBLE; "no one is dead until warm and dead"	Core temperature measurement; actively rewarm to ≥36°C before brain death examination; all clinical findings may normalize with rewarming
CNS depressant drug intoxication	History of overdose or recent sedative administration; barbiturates, benzodiazepines, opioids, propofol, alcohol; can mimic all brain death findings including flat EEG	Comprehensive toxicology screen; specific drug levels; wait ≥5 half-lives for clearance; if cannot wait, use ancillary testing (cerebral blood flow study NOT affected by drugs)
Severe metabolic derangement	Hepatic encephalopathy (ammonia >200); severe hyponatremia or hypernatremia; diabetic coma; severe uremia; hyperosmolar state	CMP; ammonia; osmolality; ABG; correct derangement and reassess; if uncorrectable, ancillary testing
Locked-in syndrome	Basilar artery occlusion/pontine stroke; patient is CONSCIOUS but appears unresponsive; preserved vertical eye movements and blinking; normal EEG	Ask patient to "look up" and "blink"; EEG shows normal alpha rhythm; MRI brainstem shows pontine lesion; brain death exam: pupils reactive, corneal reflex may be present
Guillain-Barre syndrome (severe/Miller Fisher variant)	Ascending paralysis; areflexia; may have facial diplegia and ophthalmoplegia; cranial nerve involvement can mimic brainstem areflexia	CSF: albuminocytologic dissociation (elevated protein, normal cells); NCS/EMG: demyelinating pattern; anti-GQ1b antibodies; EEG shows normal cerebral activity; cerebral blood flow is NORMAL
High cervical spinal cord injury	Complete cord transection above C3 → apnea, quadriplegia, areflexia below lesion; BUT brainstem reflexes PRESERVED (pupillary, corneal, oculovestibular)	MRI cervical spine; brainstem reflexes intact on examination; EEG shows cerebral activity; cerebral blood flow normal
Severe myasthenia gravis crisis	Generalized weakness including cranial nerve and respiratory muscles; may appear unresponsive with absent reflexes; pupil reactivity usually preserved	Edrophonium/ice pack test; NCS with repetitive stimulation: decremental response; acetylcholine receptor antibodies; EEG: normal cerebral activity
Baclofen intoxication (intrathecal pump malfunction)	Intrathecal baclofen overdose can cause deep coma, areflexia, absent respiratory drive; REVERSIBLE	History of intrathecal baclofen pump; check pump function; CSF baclofen level; supportive care until clearance; EEG may show slowing but NOT electrocerebral inactivity; cerebral blood flow normal
Posterior fossa hemorrhage with brainstem compression	Acute cerebellar hemorrhage compressing brainstem; may present with absent brainstem reflexes; potentially surgically treatable	CT head: posterior fossa hemorrhage; neurosurgical evaluation for emergent decompression BEFORE declaring brain death; surgical evacuation may be life-saving
Severe hypothyroidism (myxedema coma)	Profound hypothermia, coma, hypoventilation, bradycardia; very slow reflexes may appear absent	TSH markedly elevated; free T4 very low; treat with IV levothyroxine and hydrocortisone; reassess after thyroid hormone replacement

Conditions Causing Irreversible Coma (NOT Brain Death)

Condition	Key Features	Brain Death Status
Persistent vegetative state (UWS)	Eyes open, sleep-wake cycles, no awareness; brainstem function INTACT	NOT brain death — brainstem reflexes present; breathing spontaneously
Minimally conscious state	Inconsistent but reproducible evidence of awareness; follows commands intermittently	NOT brain death — evidence of consciousness
Anencephaly	Congenital absence of cerebral hemispheres; brainstem present and functioning	NOT brain death — brainstem functions intact; different legal/ethical considerations

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6. MONITORING PARAMETERS

During Brain Death Evaluation and Donor Management

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Core temperature (esophageal/rectal/bladder)	Continuous	≥36°C (96.8°F) for valid examination; 36-38°C for donor management	If <36°C: active rewarming; do NOT proceed with examination; if >38°C: cooling measures	STAT	STAT	-	STAT
Arterial blood pressure (invasive — arterial line)	Continuous	MAP ≥60 mmHg for valid exam; MAP 60-100 for donor management	Hypotension: IV fluids → vasopressin → norepinephrine; escalate per donor protocol	STAT	STAT	-	STAT
Heart rate and cardiac rhythm (telemetry)	Continuous	Sinus rhythm; HR 60-120; avoid hemodynamically significant arrhythmias	Arrhythmia: correct electrolytes (K, Mg, Ca); standard ACLS if needed; atropine test: no HR response expected in brain death	STAT	STAT	-	STAT
SpO2 (pulse oximetry)	Continuous	≥95% (≥92% during apnea test is acceptable if O2 supplementation ongoing)	<85% during apnea test → ABORT test and reconnect ventilator; troubleshoot; consider ancillary testing	STAT	STAT	-	STAT
Urine output (Foley)	Hourly	0.5-3 mL/kg/hr; >300 mL/hr = likely DI	DI (>300 mL/hr, dilute urine, rising Na): desmopressin 1-4 mcg IV; replace volume; monitor sodium q2h	-	STAT	-	STAT
Serum sodium	q2-4h (more frequently if DI)	135-155 mEq/L for donor management; avoid rapid swings	Rising Na + polyuria → DI → desmopressin + volume replacement; falling Na → adjust desmopressin	STAT	STAT	-	STAT
ABG (arterial blood gas)	q4-6h; pre/post apnea test	pH 7.25-7.45; PaCO2 35-45 (baseline); PaO2 >80; apnea test targets	Acidosis: sodium bicarbonate if pH <7.2; ventilator adjustments; apnea test ABGs are critical for determination	STAT	STAT	-	STAT
Blood glucose	q1-2h during insulin drip; q4h otherwise	120-180 mg/dL	<70: D50 bolus; >180: start/increase insulin infusion; steroid-induced hyperglycemia common	-	STAT	-	STAT
Serial neurologic checks (GCS, pupils, brainstem reflexes)	q1-2h pre-determination	GCS 3; fixed dilated pupils bilaterally; absent brainstem reflexes	Any improvement → brain death cannot be diagnosed; reassess; look for confounders	STAT	STAT	-	STAT
CVP (central venous pressure)	Continuous if CVC placed	4-12 mmHg for donor management	Low: volume resuscitation; high: restrict fluids (protect lungs); diuretics if pulmonary edema	-	STAT	-	STAT
Troponin (serial)	q6-12h during donor management	Trending down; severely elevated → cardiology evaluation	Rising troponin: echocardiography; may affect cardiac donation suitability; neurogenic cardiac injury common	-	STAT	-	STAT

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7. DISPOSITION CRITERIA

Brain Death Evaluation Disposition

Disposition	Criteria
ICU admission	All patients undergoing brain death evaluation require ICU-level care; mechanical ventilation; continuous hemodynamic monitoring; arterial line; vasopressor support; hourly neuro checks; controlled environment for apnea testing
Continue ICU for organ donation	After brain death declaration with organ donation consent: continue ICU-level care for donor management (hemodynamic optimization, hormone replacement, organ preservation); OPO manages care; OR scheduling for organ recovery
Ventilator discontinuation	After brain death declaration WITHOUT organ donation: family notification → reasonable time for family to visit → ventilator discontinuation; patient is legally dead — ventilator removal is NOT "withdrawal of care"
Morgue/funeral home	After ventilator removal (non-donor) or after organ recovery (donor): standard post-mortem care; death certificate completed with time of brain death determination; autopsy per institutional/legal requirements
Delayed determination	If confounders cannot be excluded (e.g., recent sedative administration): continue ICU care; repeat evaluation after drug clearance (≥5 half-lives); consider ancillary testing if clearance uncertain or delayed
Contested brain death	If family contests: ethics consultation; social work; chaplain; legal counsel; reasonable accommodation; NJ religious exemption if applicable; continue ICU care during resolution
Transfer considerations	If institution lacks resources for ancillary testing: arrange transfer to facility with nuclear medicine, angiography, or neurophysiology capabilities; OPO may facilitate transfer

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8. EVIDENCE & REFERENCES

Key Guidelines

Guideline	Source	Year	Key Recommendation
Evidence-Based Guideline Update: Determining Brain Death in Adults — Report of the Quality Standards Subcommittee of the AAN	American Academy of Neurology (AAN)	2010	Established standardized clinical examination protocol; apnea test methodology; ancillary test recommendations; single examination sufficient if protocol followed
Practice Guideline Update: Disorders of Consciousness — Brain Death (Death by Neurologic Criteria)	AAN/AHA/NCS Joint Guideline	2023	Updated DNC guidelines: minimum qualifications for examiners; checklist-based approach; core temperature ≥36°C; specific drug clearance guidance; expanded ancillary test options; legal/ethical framework
Uniform Determination of Death Act (UDDA)	National Conference of Commissioners on Uniform State Laws	1981 (revised 2023)	Legal framework: death = irreversible cessation of circulatory/respiratory functions OR irreversible cessation of all brain functions including brainstem; adopted by all 50 states
Management of the Potential Organ Donor in the ICU — Society of Critical Care Medicine/ACCP/AOPO Consensus Statement	SCCM/ACCP/AOPO	2015	Donor management: hormone replacement therapy (vasopressin, T4, methylprednisolone, insulin); hemodynamic targets; lung-protective ventilation; fluid management; goal-directed therapy
HRSA/UNOS Critical Pathway for the Organ Donor	HRSA/UNOS	2002 (updated)	Standardized donor management protocol; hormone replacement therapy bundle; hemodynamic goals; organ-specific management; OPO coordination

Landmark Studies and Key Evidence

Study	Finding	Impact
Wijdicks et al. AAN Practice Parameter (2010)	Evidence-based review of brain death determination; no published reports of recovery after proper brain death determination	Established current clinical standard; confirmed that properly performed brain death examination is 100% specific
Greer et al. AAN/AHA/NCS Guideline Update (2023)	Updated 2010 guideline; expanded prerequisites; clarified confounder management; updated ancillary test recommendations; addressed legal/ethical issues	Current standard of practice; checklist-based approach reduces errors; addresses previously ambiguous areas
Shemie et al. International Guidelines for DNC (2014)	World Brain Death Project; international consensus on minimum clinical standards for brain death determination	Harmonized international standards; framework for countries developing brain death protocols
Nair-Collins et al. Survey of Brain Death Policies (2015)	Significant variability in hospital brain death policies across the United States; many policies outdated or incomplete	Highlighted need for policy standardization; drove AAN 2023 guideline development
Malinoski et al. Donor Management Goals (2013)	Achieving ≥4 of 6 donor management goals (MAP, CVP, Na, glucose, pH, PaO2/FiO2) significantly increases organ yield per donor	Standard donor management targets; bundled approach improves transplant outcomes
Nikas et al. Brain Death and Organ Donation (2016)	Family approach by trained OPO requestors yields higher donation consent rates than physician-initiated requests	OPO-led family approach is standard; physicians should not approach families about donation without OPO coordination
Bernat JL. Controversies in Defining and Determining Death (2013)	Philosophical and clinical analysis of brain death concept; addressed criticisms and confirmed validity of whole-brain death criterion	Intellectual framework supporting brain death as death; addressed critics of concept
Lustbader et al. Second Brain Death Examination (2011)	No patient found to have different results on second brain death examination when confounders properly excluded in first examination	Supports AAN position that single examination is sufficient when properly performed; second examination is institutional/legal requirement, not clinical necessity
Powner et al. Hormonal Therapy for Organ Donors (2004)	Thyroid hormone replacement improves cardiac function and donor hemodynamics; reduces vasopressor requirements	Hormonal resuscitation bundle became standard donor management practice

Ancillary Test Evidence Summary

Test	Sensitivity	Specificity	Key Limitation	Source
Cerebral angiography (4-vessel)	95-100%	~100%	Invasive; requires transport; contrast load; technically demanding	Flowers & Patel, Radiology 2000
Tc-99m HMPAO SPECT	94-100%	~100%	Isotope availability; transport required; posterior fossa assessment	Bonetti et al., AJNR 1995
EEG (electrocerebral inactivity)	90-95%	High	Does NOT assess brainstem; confounded by drugs, hypothermia; ICU artifact	Young et al., Can J Neurol Sci 2006
CTA (brain death protocol)	85-95%	Variable (protocol-dependent)	Sensitivity varies by scoring system and timing; false negatives reported; not universally accepted	Frampas et al., AJNR 2009
TCD (transcranial Doppler)	89-99%	97-100%	Operator-dependent; 10-15% inadequate windows; not universally accepted as sole test	Monteiro et al., J Neuroimaging 2006

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CHANGE LOG

v1.1 (January 30, 2026) - Standardized all treatment table dosing fields to use structured :: format across Sections 3A, 3B, 3C - Added Route values for apnea test procedural steps (Section 3B) and mechanical ventilation (Section 3C) - Renamed Section 4A header from "Essential Recommendations" to "Referrals & Consults" for cross-plan consistency - Renamed Section 4B header from "Family Communication and Support" to "Patient/Family Instructions" for cross-plan consistency - Renamed Section 4C header from "Legal and Documentation Requirements" to "Legal, Ethical & Documentation" for cross-plan consistency - Improved "Active rewarming" dosing with structured format and Route designation - Improved "Correction of metabolic derangements" dosing with specific agent doses (D50, NaHCO3, calcium gluconate) - Improved "Goal-directed fluid therapy" dosing with structured rate and format - Added structured dosing format to all 6 apnea test steps for clinical tool compatibility - Checker validation: 50/60 → 56/60 (83% → 93%)

v1.0 (January 30, 2026) - Initial template creation - Comprehensive brain death evaluation protocol per AAN 2023 updated guidelines - Full prerequisites, clinical examination, apnea test protocol - Ancillary testing indications and options - Donor management protocol (HRSA/UNOS hormone replacement therapy bundle) - Family communication and legal/ethical framework - Differential diagnosis of brain death mimics - Documentation requirements and disposition criteria

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APPENDIX A: Brain Death Clinical Examination Checklist

BRAIN DEATH / DEATH BY NEUROLOGIC CRITERIA — CLINICAL EXAMINATION

PREREQUISITES (ALL must be met before proceeding):
□ Known cause of coma established (imaging, clinical history)
□ Condition is irreversible (treatment options exhausted or not available)
□ Core temperature ≥36°C (96.8°F) — document: ____°C
□ Systolic BP ≥100 mmHg (or MAP ≥60 mmHg) — document: ____/____
□ No CNS depressant drugs at active levels (toxicology screen reviewed)
   □ Drug screen results: ________________________
   □ Last sedative/opioid given: _________ at _________
   □ Drug levels (if applicable): ________________________
□ No neuromuscular blocking agents active (train-of-four 4/4 if given)
□ No severe electrolyte, acid-base, or endocrine derangement
   □ Na: _____ Glucose: _____ pH: _____ Ca: _____
□ Not hypothermic (core temp ≥36°C confirmed)

CLINICAL EXAMINATION:

1. COMA
□ No eye opening to any stimulus (verbal, painful)
□ No motor response to central pain (nail bed, supraorbital, sternal)
   □ Note: Spinal reflexes may be present and do NOT preclude brain death
   (triple flexion, finger flexion, Lazarus sign are SPINAL reflexes)

2. BRAINSTEM REFLEXES — ALL must be ABSENT:

□ Pupillary light reflex — ABSENT bilaterally
  □ Pupils: fixed, mid-position (4-9 mm) or dilated (>6 mm)
  □ Direct light: No response R _____ L _____
  □ Consensual light: No response R _____ L _____
  □ Note: Round, oval, or irregular shape acceptable; mydriatic drops excluded

□ Corneal reflex — ABSENT bilaterally
  □ Cotton wisp or saline drop applied to cornea directly
  □ No blink response R _____ L _____

□ Oculocephalic reflex (Doll's eyes) — ABSENT
  □ Rapid head turning side-to-side: Eyes remain midline (no movement)
  □ Note: Do NOT perform if cervical spine injury suspected/uncleared

□ Oculovestibular reflex (Cold calorics) — ABSENT bilaterally
  □ Head elevated 30°; inspect tympanic membrane (clear, no perforation)
  □ 50 mL ice water irrigated into each ear canal
  □ Observe 1 minute per ear; 5 minutes between ears
  □ No eye deviation R _____ L _____

□ Gag reflex — ABSENT
  □ Stimulate posterior pharynx with tongue depressor or suction catheter
  □ No gag response _____

□ Cough reflex — ABSENT
  □ Deep tracheal suctioning via ETT to carina
  □ No cough response _____

□ Jaw reflex — ABSENT (optional per AAN 2023)

□ Atropine test — No heart rate increase (optional)
  □ Atropine 1 mg IV → Heart rate change: ____
  □ <3% increase = absent vagal response (consistent with brain death)

3. APNEA TEST
□ Pre-oxygenated with FiO2 1.0 x ≥10 min
□ Pre-test ABG: pH ____ PaCO2 ____ PaO2 ____
□ Ventilator disconnected; O2 catheter placed at carina (6-10 L/min)
□ Observed for ____ minutes (minimum 8-10 minutes)
□ No respiratory effort observed: □ TRUE □ FALSE
□ Post-test ABG: pH ____ PaCO2 ____ PaO2 ____
□ PaCO2 ≥60 mmHg: □ YES □ NO
□ PaCO2 rise ≥20 mmHg above baseline: □ YES □ NO
□ APNEA TEST RESULT: □ POSITIVE (absent drive) □ INCONCLUSIVE □ ABORTED
□ If aborted, reason: ________________________________

DETERMINATION:
□ Brain death / DNC confirmed
□ Time of death: ____:____ on ____/____/____
□ Examiner name: ________________________ MD/DO
□ Examiner credentials: ________________________
□ Second examiner (if required): ________________________

NOTIFICATIONS:
□ Family notified: Time ____:____
□ OPO notified: Time ____:____ Contact: ____________
□ Medical examiner/coroner notified (if applicable): Time ____:____
□ Attending physician notified: Time ____:____

APPENDIX B: Apnea Test Troubleshooting

APNEA TEST — COMMON PROBLEMS AND SOLUTIONS

PROBLEM: Patient desaturates (SpO2 <85%) during test
→ SOLUTION: Reconnect ventilator immediately
→ Ensure adequate pre-oxygenation (PaO2 >200 before disconnection)
→ Verify O2 flow rate at carina (6-10 L/min)
→ Consider T-piece with CPAP 5-10 cmH2O instead of open disconnection
→ If cannot maintain SpO2 >85% for 8-10 min: ANCILLARY TEST required

PROBLEM: Hemodynamic instability (MAP <60) during test
→ SOLUTION: Optimize vasopressors BEFORE test
→ Bolus vasopressin 1 unit IV before disconnection
→ Ensure adequate volume resuscitation
→ If unstable despite optimization: ANCILLARY TEST required

PROBLEM: Baseline PaCO2 elevated (chronic hypercarbia, e.g., COPD)
→ SOLUTION: Document patient's chronic PaCO2 baseline
→ Adjusted targets: PaCO2 must rise ≥20 mmHg above CHRONIC baseline
   AND reach ≥60 mmHg absolute
→ May require longer observation period
→ AAN 2023: Acceptable to use chronic baseline as starting point

PROBLEM: PaCO2 target not reached after 8-10 minutes
→ SOLUTION: Continue observation up to 15 minutes if hemodynamically stable
→ Draw repeat ABG at 10 and 15 minutes
→ If still not reached: test is INCONCLUSIVE — need ancillary test
→ Note: CO2 typically rises 3-5 mmHg/min during apnea

PROBLEM: Observed movement during test
→ SOLUTION: CAREFULLY distinguish:
  - Spinal reflexes (acceptable — do NOT negate brain death):
    • Triple flexion of legs
    • Finger flexion/extension
    • Shoulder shrugging (rare)
    • Lazarus sign (arm raising — spinal cord mediated)
  - TRUE respiratory effort (NEGATES brain death):
    • Rhythmic chest/abdominal excursion
    • Active diaphragmatic contraction
    • Gas flow through ETT
→ If uncertain: ABORT test, reassess, video record if available

PROBLEM: Patient on ECMO
→ SOLUTION: ECMO adds significant complexity to brain death determination
→ Apnea test on ECMO requires specialized protocol:
  - Reduce ECMO sweep gas to minimum/off
  - Wait for PaCO2 to rise to target via native circulation
  - Institutional-specific protocol REQUIRED
→ Consider ancillary testing (cerebral blood flow study) instead
→ Consult institutional brain death policy and ECMO team

APPENDIX C: Donor Management Goals (DMG) Quick Reference

DONOR MANAGEMENT GOALS — HRSA/UNOS CRITICAL PATHWAY

TARGET: Achieve ≥4 of 6 goals to maximize organs per donor

╔═══════════════════════╦═════════════════════════════════════╗
║ Parameter             ║ Target                              ║
╠═══════════════════════╬═════════════════════════════════════╣
║ MAP                   ║ 60-100 mmHg                         ║
║ CVP                   ║ 4-12 mmHg                           ║
║ Serum sodium          ║ 135-160 mEq/L                       ║
║ Blood glucose         ║ 120-180 mg/dL                       ║
║ Arterial pH           ║ 7.25-7.45                           ║
║ PaO2/FiO2 ratio      ║ ≥300                                ║
╚═══════════════════════╩═════════════════════════════════════╝

HORMONE REPLACEMENT THERAPY (HRT) BUNDLE:
1. Vasopressin: 1 unit IV bolus → 0.5-2.4 units/hr
2. Levothyroxine (T4): 20 mcg IV bolus → 10 mcg/hr
   (or T3: 4 mcg bolus → 3 mcg/hr)
3. Methylprednisolone: 15 mg/kg IV x1 (max 1 g)
4. Insulin drip: Target BG 120-180 mg/dL

VENTILATOR SETTINGS:
• Tidal volume: 6-8 mL/kg IBW
• PEEP: 5-10 cmH2O
• FiO2: Titrate to SpO2 >95%
• Target: PaO2/FiO2 ≥300
• Recruitment maneuvers PRN

FLUID MANAGEMENT:
• CVP 4-12 mmHg
• Balanced crystalloid preferred
• Replace DI losses mL-for-mL
• Avoid overhydration (damages lungs)
• Transfuse if Hgb <7 g/dL

ELECTROLYTES:
• Na: 135-160 (desmopressin for DI)
• K: 3.5-5.0 (replace aggressively)
• Mg: >1.5 mg/dL
• Ca (ionized): 1.0-1.3 mmol/L
• Phos: 2.5-4.5 mg/dL

APPENDIX D: State-Specific Considerations

State/Jurisdiction	Special Requirement	Notes
New Jersey	Religious exemption: if family objects to brain death on religious grounds, patient remains legally alive on ventilator	Only state with statutory religious exemption; physician must accommodate; no time limit specified
New York	Must provide "reasonable accommodation" for religious and moral objections to brain death	Not as absolute as NJ; case-by-case; institutional policies vary
California	Requires "reasonable time" for family before ventilator withdrawal after brain death; OPO notification required	Recently legislated additional family protections
Most states	1 examination by qualified physician sufficient per AAN guidelines; institutional policy may require 2 examinations	Check institutional policy and state regulations; some states specify examiner qualifications
Pediatric	AAP/CNS/SCCM 2011: 2 examinations required; observation period varies by age (24h for term newborns to 30 days; 12h for 30 days to 18 years); longer intervals recommended in younger children	This template covers ADULTS only; pediatric brain death determination follows separate guidelines

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This template represents the initial build phase (Skill 1) and requires validation through the checker pipeline (Skills 2-6) before clinical deployment.