Protocol for Certification of Pediatric Death by Neurologic Criteria
Represents guidelines from the American Academy of Neurology
Diagnosis: _______________________________________
Examination #1
Examination #2
1. Date and Time of Exam(s
Date: ____Time: _____
Physical Exam
CT
MRI Other
Date: ___Time: ____
Physical Exam
CT MRI
Other
BP:_______ P:_____
BP:_______ P:_____
SaO2:
SaO2:
Temp:
Temp:
2. Etiology of Coma confirmed by:
Circle all that apply
3. Complicating Conditions
(A) Vital signs: If hemodynamically unstable, consider Ancillary
Tests listed below
(B) Record SaO2 or PaO2 - 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
95F)
(D) Neuromuscular paralyzing agents (Check train-of-four)
(E) Drug or metabolic Intoxication (if in doubt, consider ancillary tests listed
below)
Specify drug levels (if applicable)
4. Evaluation of Coma
(A) Response to deep painful stimuli
(B) Deep muscular movements (except spinal reflexes)
5. Evaluation of Brain Stem Function Documented
(A) Pupillary response to light
(B) Corneal/blink reflexes
(C ) Oculocephalic (Doll’s eyes) reflexes
(D) Oculovestibular (cold caloric) reflexes
(E) Gag and reflex
(F) Cough reflex
(G) Suck (newborns only)
6. ApneaTest
(A) Respiratory reflex during apnea test
(B) PCO2 results:
 pCO2 prior to apnea test (recommended is 40-50 mmHg)
 Ending pCO2 (should be greater than 60 mmHg
7. Ancillary Tests (if clinical examination is unreliable or inconclusive)
❏ Cerebral angiography/Perfusion Study
❏ Nuclear Med. Cerebral Perfusion Study
❏ CT angiography
❏ EEG
❏ Transcranial Dopplers
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
❏ Absent ❏ Present
❏ Absent ❏ Present
❏ Absent ❏ Present
❏ Absent ❏ Present
❏
❏
❏
❏
❏
❏
❏
❏ Absent
❏ Absent
❏ Absent
❏ Absent
❏ Absent
❏ Absent
❏ Absent
Absent
Absent
Absent
Absent
Absent
Absent
Absent
❏ Absent
❏
❏
❏
❏
❏
❏
❏
Present
Present
Present
Present
Present
Present
Present
❏ Present
❏ Absent ❏Present
Baseline pCO2 =_____
Baseline pCO2 =___
Final pCO2 = _______
Final pCO2 = ______
Results
Results
Results
Results
Results
Results
Results
Results
Results
Results
Comments: _____________________________________________________________________________________
**
❏ Present
❏ Present
❏ Present
❏ Present
❏ Present
❏ Present
❏ Present
The diagnosis of Brain Death is made when:
(1) If 2 through 5 above are answered “Yes” or “Absent”, AND
(2) Either an Apnea Test is definitive, or one of the listed Ancillary Tests is conclusive.
(3) 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.
Date of Death: __________
Time of Death: _________
Physician Signature: ____________________________
Date: _______
Time: ________
Examination #2 (if applicable):
Physician Signature: ____________________________
Date: _______
Time: ________