Brain dead?

Author: Angus Perks, Abdellah Aroui / Editor: Nick Tilbury / Codes: MHC8, NeuC7, PhC1, PhP2, RC2, RP8, SLO2, SLO3, SLO7 / Published: 23/09/2024

You’re working in Resus and receive a paramedic pre-alert for a 51-year-old male being brought in with a GCS of 3 and respiratory rate of 12. The rest of his observations at pre-alert are:

• Blood pressure 141/84
• Heart rate 77
• Respiratory Rate 12
• Oxygen saturation 100% (on 15 litres supplementary oxygen)
• Temperature 35.4

At handover the paramedics tell you that he was found slumped on his sofa, having last been seen well the night before. He has a past medical history of multiple sclerosis, depression, and previous suicide attempts. He lives alone although has assistance with cleaning, shopping, and washing.

Intra-muscular naloxone has had no effect on either his respiratory rate or conscious level.

On examination he is tolerating an oropharyngeal airway (OPA) and makes no response at all to painful stimulation. He is globally hypotonic and areflexic.  His GCS is E1V1M1. Pupils are fixed and dilated at 8mm with no gaze deviation. Systemic examination reveals no other obvious abnormalities.

You administer 800mcg IV naloxone which again has no effect.

A VBG shows the following:

• pH 7.142
• pCO2 10.8
• pO2 7.85
• BE 0.6
• HCO3 27.8
• COHb 1.4
• MetHb 0.5
• Hb 177
• Lac 2.1
• Glucose 6.6