Organ Donation in the Emergency Department
Though it may not seem as important as some of the things we do in ED Critical Care, managing the potential organ donor can lead to many lives saved. In this episode I interview Isaac Tawil, an Emergency Intensivist of University of New Mexico Health Sciences and associate medical director of New Mexico Organ Donor Services.
Here are the current standards for determining brain death
Wijdicks et al. Evidence-based guideline update: Determining Brain Death in Adults
Brain Death Checklist
Tips on the Exam
from Wijdicks Crit Care 2020;24:648
Mesencephalon
Need only test pupil response to high-intensity flashlight. Pupils are mid-position (4-6 mm)
Use a Magnifying Glass if you don't have a pupilometer
Pons
Corneals (cotton swab or water)
Oculocephalic-Turn from middle to the side 90 degrees on both sides.
Cold calorics-30 mls of ice water. Normal response is slow deviation of eyes towards syringe
Pain Response to nailbeds, supraorbital
Medulla
Gag reflex with yankeur
No cough during deep suctioning
Checklist from the Paper
What to Exclude
J Crit Care 2019;53:212
Here is a video of Dr. Tawil demonstrating the brain death exam
Additional New Information
More on EMCrit
Additional Resources
UK Guidance on the use of CTA of the brain as ancillary test for brain death [10.1111/anae.15950]
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Thank you, very straightforward and apropo to an EP’s needs; yet, this topic has been often ignored.
I have been guilty of forgetting about it sometimes myself.
Out of interest, Australia has not long introduced a program (at some fair cost) to inrease awareness of organ donation. A recent survey demonstrated that donation rates dropped in the past year despite this.
Also, Australian Federal Police are currently investigating what might turn out to be its first case of “human trafficking for procurement of an organ.” Yipe!
these conversations are consistently held at the worst possible time; makes it so much harder. I think the human trafficking is going to keep getting worse. Perhaps stem cell research will make all of this academic in a couple of decades.
As with so many things that don’t automatically register in our consciousness, the only way to really improve donation rates, and rates of physicians referring for possible donation, is if it made the EASIEST thing to do…and unfortunately, this is pretty unlikely to happen.
absolutely, it should be opt out, not opt in
Chris Johnson writes: Hey Scott, I am an avid emcrit follower. I have commented on your show a couple times and you have always been awesome. But this time I have a question. I just listened to the organ procurement episode and I was thinking: Should paramedics consider this prehospital. I mean, we call trauma codes on scene without any resus performed, and we can call medical codes after 10 mins of straight asystole or PEA. I work for a flight program in Tampa, Florida as well as a fire department. My question is should the powers that be branch… Read more »
Hi Scott I loved this podcast. Thanks for putting it out. I was hoping to gauge whether there is a large degree of practice variation across the EMCrit listeners with regard to admitting patients to the ICU from the ED prior to gaining consent from the family for organ donation. Clearly, practice is going to vary depending on which country we work in and the cultural/legal frameworks therein. Our hospital has a small ICU (one ICU bed for every 100 floor beds) so an ICU bed is an incredibly precious resource. Are most listeners admitting patients to the ICU prior… Read more »
Hey buddy, It even varies by State in the US. In NY, we are barred from speaking with the family about donation, it is done by donation services. Usually this occurs once the patient has already hit the ICU. I’m not sure how the donation process affects whether or not you take the patient to the ICU. Assuming the patient is intubated, if they yes you’ll take them. If they say no, are you saying you would do a palliative extubation in the ED–if so, that makes sense. But what about the patients whose prognosis is not clear yet. Would… Read more »
Yes, I think so. In fact, I found this article in the EMJ which was written by Bernard Foex which advocates delaying the decision to withdraw. A 72 hour observation period for those patients where the prognosis is more guarded is prudent.
http://emj.bmj.com/content/early/2016/12/28/emermed-2016-206397