Devastating Brain Injuries: Assessment and Management Part I: Overview of Brain Death

INTRODUCTION Perhaps one of the greatest achievements in medicine to date, organ transplantation has transformed the lives of thousands – bringing life to those who would surely have died without it. This achievement is dependent upon a generous gift from another person. From one deceased donor up to 55 lives may be saved or improved.1 With progressive advances in the trauma system, emergency physicians (EPs) are faced with more severely injured trauma patients, including the potentially brain-dead. The purpose of this three-part series is to present the components of determining brain death, to discuss the pathophysiology unique to brain-dead patients and to outline an algorithm based on that physiology to improve the care of the brain-dead patient. Rather than selectively neglect the brain-dead patient, active management while the patient is still in the emergency department (ED), specialty consultation and critical care can significantly enhance the likelihood of successful organ donation, turning a tragic loss into a rewarding patient encounter. The majority of transplanted organs come from braindead or cadaveric donors. As most of these donors enter the healthcare system through the ED as either trauma patients with brain injuries or medical patients with acute intracranial hemorrhage, EPs are often involved in the diagnosis, referral, and initial stabilization of these patients. When these injuries would not benefit from neurosurgical or neurologic intervention and are deemed to be non-survivable, they are “devastating brain injuries.” The EP’s goal shifts to maintaining hemodynamic stability to diagnose brain death, should it occur. Furthermore, we must prepare the family for devastating news and allow them to begin the grieving process. EPs and trauma surgeons are often involved in discussions of end-of-life care and intensive care management of critical illness and injury. Therefore, both groups have the ability to impact organ donation, transplant frequency and success. Table 1. Glasgow Coma Scale