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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