Brain dead and bleeding

[Ronald Gross]

Dean,

Clinical brain death legally means that you would be operating on a
dead patient, and I am not sure how the ethicists would view that. 
Personally, IF my patient were brain dead, and was declared so on 2
separate brain death exams separated by 6 hours and the patient then let
loose with bleed from a Grade IV spleen I would operate ONLY if the
patient was determined to be an organ donor, and was set to go to the OR
for procurement when the second brain death exam had been completed.  If
the patient was declared brain dead, and was therefore legally dead, and
then bled, I would NOT operate.

On the other hand, IF the patient were not yet declared brain dead and
that spleen let loose, then I would be obliged to operate, or I could
rightfully be accused of abandonment - or worse........

Ron

>>> "Dean Lutrin" <deanlutrin at gmail.com> 12/21/2006 3:48 PM >>>
Ron, agree wholeheartedly. 2 separate scenarios - clinically brain
dead, and
severe head injury. I think that we would all agree to operate on
severe
head injury, but what is your opinion on clinically brain dead with
(potentially) reversible intra-abdominal bleeding?

Dean

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] 
On Behalf Of Ronald Gross
Sent: Thursday, December 21, 2006 9:07 PM
To: Critical Care mailing list Trauma &amp
Subject: Re: Brain dead and bleeding

Absolutely correct - read my post again, and while not well stated you
will note that I was referring to the CT that was discussed.  Later on
I
referred to a study that proved absence of blood flow, and clearly a 4
vessel angio is the radiologic test that serves to date as the "gold
standard", done if the patient is not stable enough to tolerate an
apnea
test..........

>>> Ben Reynolds <aneurysm_42 at yahoo.com> 12/21/2006 1:53 PM >>>
A four vessel angiogram showing a cutoff sign at the
skull base for all four vessels without any
intracranial reconstitution or collateralization of
contrast is the conditio sine qua non radiographic
image of a brain dead individual, assuming a GCS of 3.

You'd be hard pressed to find a clinical exam for
brain death which could refute that.

Ben Reynolds, PA-C
Pittsburgh, PA
--- Ronald Gross <Rgross at harthosp.org> wrote:

> Dean,
> 
> The determination of brain death CANNOT be made
> radiologically, and
> therefore a CT that shows injuries that are
> supposedly not compatable
> with life does not mean that the patient is brain
> dead.  Brain death is
> a clinical determination that depends on the absence
> of any and all
> brain stem function and apnea in the presence of
> profound hypercarbia
> and high PO2, or proof that there is no blood flow
> to the brain. 
> 
> In my opinion, there is no question in my mind that
> the patient you
> referenced should have been operated on.  The
> physician that was
> "roundly criticized" got off easy, as I see it.
> 
> Ron
> 
> >>> "Dean Lutrin" <deanlutrin at gmail.com> 12/21/2006
> 12:11 PM >>>
> Dear list
> 
> A quick question. What are your feelings on
> operating on a patient who
> comes
> into your ER brain dead with intraabdominal
> bleeding? Do you treat the
> abdomen on its own merits assuming that some of the
> low GCS may be
> attributable to hypovolaemia etc...
> 
> I am of course assuming that the patient has been
> intubated without
> drugs,
> there is no drug history etc etc...
> 
> We debated this a bit today where one of the
> surgeons did not operate
> on a
> case because the CT brain showed unsurvivable
> injuries and was roundly
> criticised.
> 
> Is this a matter of opinion or are there good
> answers?
> 
> Thanks 
> 
> Dean Lutrin
> JHB, SA
> 
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