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  #1  
Old 06-05-2012
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Medicolegal and Ethics Brain Death Question

A 45-year-old woman is admitted after having a seizure at the party. Her head CT scan shows an intracranial bleed. She is intubated because of loss of spontaneous respiration. There are no pupilary, corneal, oculocephalic or cold caloric reflexes elicited. Which of the following you should do next?

A) EEG
B) ECG
C) Urinary toxicology screen
D) Psychiatric evaluation
E) Ethics committee evaluation
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  #2  
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I think its A) EEG.
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Originally Posted by Hope2Pass View Post
I think its A) EEG.
Nope

Any other replies guys?
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Found a similar case here - A question about Brain Death Case

I read that a long time ago and still messed it up!
I think that's a confusing topic though because EEG is a part of the work up to diagnose someone brain-dead. But I guess Urine Toxicology is the right answer here ?

Good questions Casandra
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Quote:
Originally Posted by Casandra View Post
A 45-year-old woman is admitted after having a seizure at the party. Her head CT scan shows an intracranial bleed. She is intubated because of loss of spontanoiuos respiration. There are no pupilary,corneal, oculocephalic or cold caloric reflexes elicited. Which of the following you should do next?
A) EEG
B) ECG
C) urinary toxicology screen
D) psychiatric evaluation
E) ethics committee evaluation
B. ECG- to confirm death?

idk, or may be urine toxicology
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B. ECG? I am not sure.
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Quote:
Originally Posted by numbndumb View Post
B. ECG- to confirm death?

idk, or may be urine toxicology
Agreed..ECG r/o death
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Correct Answer Answer is C

The correct answer is C.
You cannot diagnose brain death before ruling out intoxication, this lady was at a party and developed seizure, she could have been taken something, you have to rule out toxicity first and then you go for the other means of confirming brain death.

Nice question though,

Where did you get this Q Casandra!
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Originally Posted by RocketMD View Post
The correct answer is C.
You cannot diagnose brain death before ruling out intoxication, this lady was at a party and developed seizure, she could have been taken something, you have to rule out toxicity first and then you go for the other means of confirming brain death.

Nice question though,

Where did you get this Q Casandra!
but why not do an ECG to check if shez actually alive in the first place? I mean u cant reverse the toxic drug if shes already dead right?
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Why use urine toxicology instead of serum toxicology? Cuz it's faster?


Quote:
but why not do an ECG to check if shez actually alive in the first place? I mean u cant reverse the toxic drug if shes already dead right?
You can just check the pulse or auscultate for this, you don't need an ECG to figure out if the heart is beating or not.
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Quote:
Originally Posted by numbndumb View Post
but why not do an ECG to check if shez actually alive in the first place? I mean u cant reverse the toxic drug if shes already dead right?
You can reverse it if it was drug toxicity.
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guys, i feel so lost here... where does her intracranial bleed fit in..?
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Quote:
Originally Posted by Hope2Pass View Post
Found a similar case here - A question about Brain Death Case

I read that a long time ago and still messed it up!
I think that's a confusing topic though because EEG is a part of the work up to diagnose someone brain-dead. But I guess Urine Toxicology is the right answer here ?

Good questions Casandra
ooops! sorry about double-posting the question. I filtered "brain stem" tagged posts to check if it had already been posted but somehow missed that.
@Hope2pass - you're indeed unquestionable Forum Master ))
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  #14  
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Default correct answer :)

correct answer is C) Urinary toxicology screen

Explanation comes from Conrad Fisher 100 Ethics Cases (comments in the brackets are mine ):


Brain death is irreversible and permanent. A beating heart that maintains blood pressure and pulse does NOT equal being alive. (so no point of ECG here). When we as physicians, determine the criteria for brain death are present, this is legally accepted standards of death.
Brain death is a loss of brainstem reflexes such as:

- pupilary light reflex
- corneal reflexes
- oculocephalic (doll's eyes) reflexes
- caloric response to iced water stimulation of the tympanic membrane
- the absence of spontaneous respirations

You can determine loos of respirations by removing the ventilator and observing for signs of respirations.

If the criteria for brain death are met, then an EEG or cerebral blood flow study are NOT necessary (I guess this is what we are often confused with). In other words, the clinical criteria of the absence of breathing and brainstem reflexes ARE MORE IMPORTANT than EEG.

Brain death should only be determined to be present IF YOU HAVE EXCLUDED other causes of markedly decreased brainstem and respiratory function. You must be certain that the patient is not suffering from an overdose of barbiturates, hypothermia, hyponatremia, hypotension, or the use of neuromuscular blocking agents such as pancuronium, vecuronium, or succinylcholine. These can all simulate brain death.

Sorry about such a long paragraph copied from the book but I always think that if there is a common confusion, facts must be straightened out in a clear way - and Fishy certainly does a very good job here

ps. of course the information in the stem about her being at the party can serve as another hint that she might have taken/been drugged... but this information aside, we should still exclude intoxication.
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Quote:
Originally Posted by numbndumb View Post
but why not do an ECG to check if shez actually alive in the first place?
in the explanation I posted above you will find the answer why not ECG.
beating heart does not mean the patient is alive.

Quote:
Originally Posted by numbndumb View Post
I mean u cant reverse the toxic drug if shes already dead right?
well if she is intoxicated you can't say right away that she is dead. that was the point of the question - we have to remember about excluding intoxication.

If she overdosed e.g. morphine and she's not breathing, does that mean that she's dead right away? No. You can try to give naloxone and put her on the respirator till she regains her respirations.
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Quote:
Originally Posted by slowpoke View Post
Why use urine toxicology instead of serum toxicology? Cuz it's faster?
I'm not saying that urine toxicology works for every drug but, from my clinical experience, in many cases you don't know when exactly the patient took the drug and all you have are metabolites that are often found only in urine (after couple of hours) and not in the blood anymore. But AGAIN, I'm not saying this is the general rule.
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Quote:
Originally Posted by Casandra View Post
A 45-year-old woman is admitted after having a seizure at the party. Her head CT scan shows an intracranial bleed. She is intubated because of loss of spontaneous respiration. There are no pupilary, corneal, oculocephalic or cold caloric reflexes elicited. Which of the following you should do next?

A) EEG
B) ECG
C) Urinary toxicology screen
D) Psychiatric evaluation
E) Ethics committee evaluation
get eeg done
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  #18  
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Quote:
Originally Posted by david khan View Post
get eeg done
nope. I posted the answer with explanation just few posts back
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  #19  
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being inpart doesnt mean that a person must have taekn some narcotix ,a person could have epilepsy .
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