脑死亡的解剖与生理.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Brain DeathAnatomy and Physiology,Joel S.Cohen,M.D.,Associate Professor of Clinical Neurology,Albert Einstein College of Medicine,Historical Perspective,Prior to the advent of mechanical respiration,death was defined as the cessation of circulation and breathing,Historical Perspective,1959,Coma depasse,Mollaret and Goulon,1968,Irreversible Coma/Brain Death,Harvard Medical School Ad Hoc Committee,1981 Uniform Determination of Death Act-Presidents Commission for the Study of Ethical Problems in Medicine,1994 American Academy of Neurology Guidelines for the determination of Brain Death,2005 NYS Guidelines for Determining Brain Death,Normal Brain Anatomy,Normal Brain Anatomy,Cerebral Cortex,Brain Stem,Reticular Activating System,Cerebral Cortex,Cognition,Voluntary Movement,Sensation,Brain Stem,Brain Stem,Pons,Cranial Nerves IV,V,VI,conjugate eye movement,corneal reflex,Reticular Activating System,Receives multiple sensory inputs,Mediates wakefulness,Causes of Brain Death,Normal,Cerebral Hemorrhage,Causes of Brain Death,Normal,Subarachnoid Hemorrhage,Causes of Brain Death,Normal,Trauma,Causes of Brain Death,Normal,Meningitis,Mechanism of Cerebral Death,Neuronal Injury,Decreased Intracranial,Blood Flow,Neuronal Swelling,Increased Intracranial,Pressure,ICPMAP is incompatible with life,Persistent Vegetative State,Normal Sleep-Wake Cycles,No Response to Environmental Stimuli,Diffuse Brain Injury with Preservation of Brain Stem Function,Locked-in Syndrome,Ventral Pontine Infarct,Complete Paralysis,Preserved Consciousness,Preserved Eye Movement,Brain Death Neurological Examination,Clinical Prerequisites:,Known Irreversible Cause,Exclusion of Potentially Reversible Conditions,Drug Intoxication or Poisoning,Electrolyte or Acid-Base Imbalance,Endocrine Disturbances,Core Body temperature 32 C,Brain Death Neurological Examination,Coma,Absent Brain Stem Reflexes,Apnea,Absence of Brain Stem Reflexes,Pupillary Reflex,Eye Movements,Facial Sensation and Motor Response,Pharyngeal(Gag)Reflex,Tracheal(Cough)Reflex,Pupillary Reflex,Pupils dilated with no constriction to bright light,Eye Movements,Occulo-Cephalic Response,“Dolls Eyes Maneuver”,Facial Sensation and Motor Response,Corneal Reflex,Jaw Reflex,Grimace to Supraorbital or,Temporo-Mandibular Pressure,Apnea Testing,Prerequisites,Core Body Temperature 32 C,Systolic Blood Pressure 90 mm Hg,Normal Electrolytes,Normal PCO2,Apnea Testing,1.Pre-Oxygenation,100%Oxygen via Tracheal Cannula,PO2=200 mm Hg,2.Monitor PCO2 and PO2 with pulse oximetry,3.Disconnect Ventilator,4.Observe for Respiratory Movement until PCO2=60 mm Hg,5.Discontinue Testing if BP 90,PO2 saturation decreases,or cardiac dysrhythmia observed,Confounding Clinical Conditions,Facial Trauma,Pupillary Abnormalities,CNS Sedatives or Neuromuscular Blockers,Hepatic Failure,Pulmonary Disease,Observations Compatible with Brain Death,Sweating,Blushing,Deep Tendon Reflexes,Spontaneous Spinal Reflexes-Triple Flexion,Babinski Sign,Confirmatory Testing,Recommended when the proximate cause of coma is not known or when confounding clinical conditions limit the clinical examination,Confirmatory Testing,EEG,Normal,Electrocerebral Silence,Confirmatory Testing,Cerebral Angiography,Normal,No Intracranial Flow,Confirmatory Testing,Technetium-99 Isotope Brain Scan,Confirmatory Testing,MR-Angiography,Confirmatory Testing,Transcranial Ultrasonography,Confirmatory Testing,Somatosensory Evoked Potentials,Concern for man and his fate must always form the chief interest of all technical endeavors.Never forget this in the midst of your diagrams and equations.,Albert Einstein,