ࡱ> mol_ .Zbjbj 8tbb VVL$$$$$$$$$&T)A$]A$$F$$r;"#P3x5"$$0$")K)##)#\A$A$i"$)V v: Protocol for Certification of Pediatric Death by Neurologic Criteria Represents guidelines from the American Academy of NeurologyDiagnosis: _______________________________________Examination #1Examination #21. Date and Time of Exam(sDate: ____Time: _____Date: ___Time: ____2. Etiology of Coma confirmed by: Circle all that apply Physical Exam CT MRI Other Physical Exam CT MRI Other3. Complicating ConditionsVital 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) O' Yes O' No O' Yes O' No (E) Drug or metabolic Intoxication (if in doubt, consider ancillary tests listed below) Specify drug levels (if applicable) O' Yes O' No O' Yes O' No4. Evaluation of Coma (A) Response to deep painful stimuliO' Absent O' PresentO' Absent O' Present (B) Deep muscular movements (except spinal reflexes) O' Absent O' PresentO' Absent O' Present5. Evaluation of Brain Stem Function Documented  (A) Pupillary response to lightO' Absent O' PresentO' Absent O' Present (B) Corneal/blink reflexesO' Absent O' PresentO' Absent O' Present (C ) Oculocephalic (Doll s eyes) reflexes O' Absent O' PresentO' Absent O' Present (D) Oculovestibular (cold caloric) reflexes O' Absent O' PresentO' Absent O' Present (E) Gag and reflexO' Absent O' PresentO' Absent O' Present (F) Cough reflexO' Absent O' PresentO' Absent O' Present (G) Suck (newborns only)O' Absent O' PresentO' Absent O' Present6. 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Ancillary Tests (if clinical examination is unreliable or inconclusive)   O' Cerebral angiography/Perfusion StudyResultsResults O' Nuclear Med. Cerebral Perfusion StudyResultsResults O' CT angiographyResultsResults O' EEGResultsResults O' Transcranial DopplersResultsResults 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. 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