CMC-NorthEast Protocol for Certification of Death by ...
|Certification of Adult Death by Neurologic Criteria |Examination |
|Represents guidelines from the American Academy of Neurology | |
|1. Date and Time of Exam |Date: _______Time: _____ |
|2. Etiology of Coma confirmed by: Please circle all that apply |CT MRI Physical Exam Other |
|3. Complicating Conditions | |
| (A) |Vital Signs: If hemodynamically unstable, consider |BP: _______ P: _______ |
| |Ancillary Tests listed below | |
| (B) |Record SaO2 or PaO2 |SaO2: |
| |Consider CPAP Apnea Test if hypoxic (SaO2 must be greater than or equal to 90%) | |
| (C) |Record body temperature (must be greater than or equal to 35 C or 95 F) |Temp: |
| (D) |Neuromuscular paralyzing present? (Check train-of-four) | ❏ Yes ❏ No |
| (E) |Evidence of drug or metabolic Intoxication? (if in doubt, consider ancillary tests listed below.) | ❏Yes ❏ No |
|4. Evaluation of Coma | |
| (A) |Response to deep painful stimuli | ❏ Absent ❏ Present |
| (B) |Deep muscular movements (except spinal reflexes) | ❏ Absent ❏ Present |
|5. Evaluation of Brain Stem Function Documented | |
| (A) |Pupillary response to light | ❏ Absent ❏ Present |
| (B) |Corneal/blink reflexes | ❏ Absent ❏ Present |
| (C) |Oculocephalic (Doll’s eyes) reflexes | ❏ Absent ❏ Present |
| (D) |Oculovestibular (cold caloric) reflexes | ❏ Absent ❏ Present |
| (E) |Gag reflex | ❏ Absent ❏ Present |
| (F) |Cough reflex | ❏ Absent ❏ Present |
|6. Apnea Test | |
| (A) |Evidence of respiratory effort | ❏ Absent ❏ Present |
| (B) |PCO2 results: |Baseline pCO2 = ________ |
| |pCO2 prior to apnea test (recommended is 40-50 mmHg) |Final pCO2 = __________ |
| |Ending pCO2 (should be greater than 60 mm Hg) | |
|7. Ancillary Tests (if clinical examination is unreliable or inconclusive) | |
| ( Cerebral angiography/Perfusion Study |Results |
| ( Nuclear Med. Cerebral Perfusion Study |Results |
| ( CT angiography |Results |
| ( EEG |Results |
| ( Transcranial Dopplers |Results |
| |
|Comments: ______________________________________________________________________________ |
|Date of Death:_______________ |Time of Death:__________ |
|Pysician Signature: ______________________________ Date _________ Time: _________ |
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