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Old 03-03-2011
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Medicolegal and Ethics A question about Brain Death Case

A 35 y/o woman is admitted after having a seizure at a party. Her head CT scan shows an intracranial bleed. She is intubated because of the loss of spontaneous respiration. There are no pupilary, corneal, oculocephalic, or cold caloric reflexes elicited. Which of the following should you do next?

A. EEG
B. EKG
C. Urine toxicology screen
D. Psychiatric evaluation
E. Ethics committee evaluation
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Old 03-03-2011
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Why do u tag this question as ethics question? it doesnt look like one!
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Default A

I would go with A. Patient seems to be in a coma so it could be helpful to get and EEG to test activity of the brain

After obtaining those results, then I would go with E, but initially I think A is the next best step
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A

Its part of the Gloscow Coma Scale protocols.
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Come on Guysssssssssssss!!!!!

Ethically, I am from stone age, but i do know that.....

She is brain dead. In a vegetative state, not in coma. No pupilary, corneal, oculocephalic, or cold caloric reflexes. All that u need for being brain dead......

We would go for E.
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Old 03-03-2011
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I think we need two flat lines on EEG to confirm, brain death.

and if u think the pt is brain dead then u dont need the approval of any commitee so it rules out E.

I would choose B. to rule out any drug toxicity because some drug toxicities can depress the brain activity & show abnormal EEG. So, in this case the condition might be reversible and life support should be continued.
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Old 03-04-2011
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Quote:
Originally Posted by doc_study View Post
I think we need two flat lines on EEG to confirm, brain death.

and if u think the pt is brain dead then u dont need the approval of any commitee so it rules out E.

I would choose B. to rule out any drug toxicity because some drug toxicities can depress the brain activity & show abnormal EEG. So, in this case the condition might be reversible and life support should be continued.
Yes, you are right. We need exclusionary criteria. This really proves that ethically I am from stone age.


Brain death characterizes the irreversible cessation of brain function. Therefore, death of the organism can be determined on the basis of death of the brain. Although some details may be dictated by local law, the standard definition permits a diagnosis of brain death upon documentation of irreversible cessation of all brain function, including function of the brain stem (Table 112-7).

Documentation of irreversibility requires that the cause of the coma be known, that the cause be adequate to explain the clinical findings of brain death, and that exclusionary criteria are absent (Table 112-8).

Confirmatory tests are sometimes used but are not required for diagnosis (Table 112-9).

A question about Brain Death Case-2011-03-04_192455.jpg
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Old 03-04-2011
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Stop You might want to disagree but..

I'll do a toxicology screen to rule out reversible causes of Brain death "which is a clinical diagnosis" & doesnt require ANY confirmatory testing. i think a big hint to my answer, is the fact that the pt was at a PARTY when everything started. an EEG may be needed to rule out electrical status epilipticus " aka silent sezuire". and again, if this was determined to be brain dead then your next step is to consult a SECOND physican to confirm the diagnosis.

A confusing Q indeed!
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Arrow The ans is C) Urine toxicology screen

Quote:
Originally Posted by drahmednawaz View Post
Yes, you are right. We need exclusionary criteria. This really proves that ethically I am from stone age.


Brain death characterizes the irreversible cessation of brain function. Therefore, death of the organism can be determined on the basis of death of the brain. Although some details may be dictated by local law, the standard definition permits a diagnosis of brain death upon documentation of irreversible cessation of all brain function, including function of the brain stem (Table 112-7).

Documentation of irreversibility requires that the cause of the coma be known, that the cause be adequate to explain the clinical findings of brain death, and that exclusionary criteria are absent (Table 112-8).

Confirmatory tests are sometimes used but are not required for diagnosis (Table 112-9).
Quote:
Originally Posted by doc_study View Post
I think we need two flat lines on EEG to confirm, brain death.

and if u think the pt is brain dead then u don't need the approval of any committee so it rules out E.

I would choose B. to rule out any drug toxicity because some drug toxicities can depress the brain activity & show abnormal EEG. So, in this case the condition might be reversible and life support should be continued.

Both of you are correct.

The ans is C) Urine toxicology screen

I got this qn from Dr. Conrad Fischer 100 cases qn book. This was really confusing me at the first time was seeing it, after I looked at the explanation then I understood. Here is what the book says... (end of life issues pg 39)

Brain death is the legal definition of death. An assault leading to brain death is a murder. Brain death is irreversible and permanent. A beating heart that maintains blood pressure and pulse does not equal alive. When we, as physicians, determine the criteria for brain death are present, this is the legally accepted standard of death.

Brain death is a loss of brainstem reflexes such as:

-->Pupilary light reflex
-->Corneal reflexes
-->Oculocephalic (doll's eyes) reflexes
-->Caloric responses to iced water stimulation of the tympanic membrane
-->The absence of spontaneous respiration


You can determine loss of respirations by removing the ventilator and observing for signs of respiration. If the criteria for brain death are met, then an EEG or cerebral blood flow study are not necessary. In other words, the clinical criteria of the absence of breathing and brainstem reflexes are more important than an EEG. This is because EEG activity would be of limited meaning if a patient meets the clinical brain death criteria.

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, hypotension, or the use of neuromuscular blocking agents such as pancuronium, vecuronium, or succinylcholine. These can all simulate brain death.
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Quote:
Originally Posted by nsesereso View Post
Why do u tag this question as ethics question? it doesnt look like one!
Ethics and Medicolegal issues are closely integrated. Brain Death cases are categorized in that category.
See this
http://www.usmle-forums.com/tags/Med...al-Ethics.html
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Old 06-14-2011
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EEG, in nbme question 10 of form 1 block 3, in the stem the patient is worked up for pupil relaxes and presence of spontaneous respirations. the last sentence is "EEG confirms electrocerebral inactivity." SO i am guessing eeg is part of the workup.
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Old 06-14-2011
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the question involved a hypertensive patient age 50 who collapsed while shopping. She also had an intracranial hemorrhage. Chances are the girl in this problem is suffering from the intracranial hemorrhage, not so much from a toxin.
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