Case #45
Heartbeats Don't Always Matter

Case Goals
  • Exclude confounders before any brain death evaluation
  • Perform a structured brain death neurologic exam once prerequisites are met
  • Have a direct conversation with Marco to explain the brain death determination and answer his questions

    • Goals

  • Exclude confounders before any brain death evaluation
  • Perform a structured brain death neurologic exam once prerequisites are met
  • Have a direct conversation with Marco to explain the brain death determination and answer his questions
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    You are the night shift resident in the ICU. A 35-year-old woman was brought in after a witnessed seizure and collapse at a house party. CT head revealed a massive intracranial hemorrhage with uncal herniation. She is now intubated and mechanically ventilated in Bed 7. Her brother Marco is at the bedside, and an attorney representing another party guest has been calling repeatedly. The cardiac monitor shows a steady sinus rhythm, but the patient has shown no neurologic response. Your job is to determine brain death and the nuances associated with that.

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    High Yield points about this case:

    • Brain death (death by neurologic criteria) is legal death in all 50 US states, even when cardiac activity continues with mechanical ventilation—the heart has its own pacemaker cells independent of the brain.
    • Before brain death testing, four reversible conditions must be excluded: hypothermia (<36°C), hypotension/shock, CNS depressant intoxication (sedatives, opioids, alcohol), and neuromuscular blockade.
    • The clinical brain death examination includes assessment of coma/unresponsiveness, absent brainstem reflexes (pupillary, corneal, oculocephalic/oculovestibular, gag, cough), and absent respiratory drive confirmed by apnea testing.
    • Ancillary tests (EEG, cerebral blood flow studies) are reserved for situations where the clinical exam or apnea test cannot be completed or confounders cannot be resolved—they are not mandatory when clinical criteria are fully met.
    • A beating heart on a ventilator reflects mechanical support of circulation, not brain function; this must be explained clearly to families using plain, compassionate language.
    • In high-stakes medicolegal contexts, clinicians should provide medical determinations and documentation but must avoid speculating on criminal charges or rendering legal opinions.
    • Clear documentation of the timing and clearance of all sedatives, analgesics, and paralytics is essential before proceeding with brain death evaluation.