NorthEast Medical Center - LifeShare Carolinas



|Protocol for Certification of Pediatric Death by Neurologic Criteria |

|Represents guidelines from the American Academy of Neurology |

|Diagnosis: _______________________________________ |Examination #1 |Examination #2 |

|1. Date and Time of Exam(s |Date: ____Time: _____ |Date: ___Time: ____ |

|2. Etiology of Coma confirmed by: Circle all that apply | Physical Exam | |

| |CT MRI Other |Physical Exam |

| | |CT MRI Other |

|3. Complicating Conditions | | |

|Vital signs: If hemodynamically unstable, consider Ancillary | | |

|Tests listed below |BP:_______ P:_____ |BP:_______ P:_____ |

| (B) Record SaO2 or PaO2 - Consider CPAP Apnea Test if hypoxic (SaO2 must be greater than or | | |

|equal to 90%) |SaO2: |SaO2: |

| (C ) Record body temperature - (must be greater than or equal to 35 C or 95F) |Temp: |Temp: |

| (D) Neuromuscular paralyzing agents (Check train-of-four) | ❏ Yes ❏ No | ❏ Yes ❏ No |

| (E) Drug or metabolic Intoxication (if in doubt, consider ancillary tests listed below) | | |

|Specify drug levels (if applicable) |❏ Yes ❏ No |❏ Yes ❏ No |

|4. Evaluation of Coma | | |

| (A) Response to deep painful stimuli |❏ Absent ❏ Present |❏ Absent ❏ Present |

| (B) Deep muscular movements (except spinal reflexes) |❏ Absent ❏ Present |❏ Absent ❏ Present |

|5. Evaluation of Brain Stem Function Documented | | |

| (A) Pupillary response to light |❏ Absent ❏ Present |❏ Absent ❏ Present |

| (B) Corneal/blink reflexes |❏ Absent ❏ Present |❏ Absent ❏ Present |

| (C ) Oculocephalic (Doll’s eyes) reflexes |❏ Absent ❏ Present |❏ Absent ❏ Present |

| (D) Oculovestibular (cold caloric) reflexes |❏ Absent ❏ Present |❏ Absent ❏ Present |

| (E) Gag and reflex |❏ Absent ❏ Present |❏ Absent ❏ Present |

| (F) Cough reflex |❏ Absent ❏ Present |❏ Absent ❏ Present |

| (G) Suck (newborns only) |❏ Absent ❏ Present |❏ Absent ❏ Present |

|6. ApneaTest | | |

| (A) Respiratory reflex during apnea test |❏ Absent ❏ Present |❏ Absent ❏Present |

| (B) PCO2 results: | | |

|pCO2 prior to apnea test (recommended is 40-50 mmHg) |Baseline pCO2 =_____ |Baseline pCO2 =___ |

|Ending pCO2 (should be greater than 60 mmHg | | |

| |Final pCO2 = _______ |Final pCO2 = ______ |

|7. Ancillary Tests (if clinical examination is unreliable or inconclusive) | | |

| ❏ Cerebral angiography/Perfusion Study |Results |Results |

| ❏ Nuclear Med. Cerebral Perfusion Study |Results |Results |

| ❏ CT angiography |Results |Results |

| ❏ EEG |Results |Results |

| ❏ Transcranial Dopplers |Results |Results |

| |

|Comments: _____________________________________________________________________________________ |

|** The diagnosis of Brain Death is made when: |

|If 2 through 5 above are answered “Yes” or “Absent”, AND |

|Either an Apnea Test is definitive, or one of the listed Ancillary Tests is conclusive. |

|Both examinations are answered “Yes” when observation period separated by ______ hours apart. |

|Time of the first determination is the legal time of death. |

| |

|On the basis of the findings recorded above, the determination of death by neurologic criteria is declared. |

| |

|Date of Death: __________ Time of Death: _________ |

|Physician Signature: ____________________________ Date: _______ Time: ________ |

| |

|Examination #2 (if applicable): |

|Physician Signature: ____________________________ Date: _______ Time: ________ |

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