Cancel the surgery and treat the patient for at least 1 month prior to reassessment.
Blood tests (FBC), ECG, CXR, ABG, and pulmonary function tests (spirometry and flow-volume loops).
Two doctors who have been fully registered with the GMC for at least 5 years, one of whom should be a consultant. Neither should be a member of the organ retrieval team.
Pupils must be fixed, dilated, and unresponsive to light. The afferent pathway is via the optic nerve (CN II) and the efferent pathway is via parasympathetic fibers carried in the oculomotor nerve (CN III).
The severe hypertension should be treated before elective surgery.
Ventilate the patient with 100% O2 for 10 minutes to ensure normocapnia, then disconnect from the ventilator. Insufflate O2 using a tracheal catheter to keep oxygen saturations ≥ 90%. Watch for respiratory effort and allow PaCO2 to increase to 6.65 kPa before terminating the test. CO2 rises at approximately 0.5 kPa per minute during apnoea; levels should be confirmed with a blood gas.
The patient must be in an apnoeic coma and ventilator dependent, irreversible brain damage of known cause must be established, and reversible causes of reduced consciousness must be identified and corrected.
The 'AMPLE' history mnemonic: Allergies, Medication, Past illnesses/Pregnancy, Last meal, Events related to the injury.
1. Donation after brainstem death (DBD) 2. Donation after cardiac death (DCD)
At least 6 hours.
The decisions around withdrawal of therapy.
The potential for non-accidental injury.
Reduced to less than 80%.
Especially when opiate analgesia has been administered.
Burns to the face, edema of the lips and oropharynx, singed eyebrows and nasal hair, carbonaceous sputum, drooling, stridor, wheeze, cough, or hoarseness.
Invasive blood pressure monitoring with an arterial line.
Cancel the surgery and treat the patient for at least 1 month prior to reassessment.
Each doctor should perform one set of tests, watched by the other. The two sets of tests can be done one after the other, and death is legally declared after the completion of the first set of tests.
Right ventricular hypertrophy.
There is an increased resistance, requiring higher doses.
The patient's best interests include not only medical best interests but also emotional and welfare issues.
Pharmacological (e.g., subcutaneous low molecular weight heparin) and mechanical thromboprophylaxis (e.g., TED stockings with or without pneumatic calf compression).
4 mL/kg crystalloid × % burn, with half given over the first 8 hours and the remaining half over the next 16 hours.
Consider peri-operative β-blocker if not contraindicated (e.g., administered 30 minutes prior to surgery) and proceed with the surgery.
In all patients where it is decided that further treatment is futile and it is in their best interests to withdraw life-sustaining therapy.
The period that begins when the systolic BP drops below 50 and oxygen saturations fall below 70%, and ends when the retrieval team begins to cool the organs that have been removed.
Anaesthesia and surgery may result in a peri-operative decline in respiratory function, with higher risks in thoracic and upper abdominal surgeries.
ACE inhibitors.
Cardiorespiratory arrest must be demonstrated on the ECG or arterial line trace.
Cancel the surgery and treat the patient for 5–7 days, then reassess.
Burns victims should be assessed following the Advanced Trauma Life Support (ATLS) guidelines, with assessment and resuscitation occurring simultaneously.
The diagnosis of hypertension and the current treatment.
The gag reflex involves no gag or cough on stimulation of the posterior pharyngeal wall. It tests the glossopharyngeal nerve (CN IX) and the vagus nerve (CN X).
There is a tendency to hypothermia, which can inhibit clotting, suppress the immune system, and impair wound healing.
Labile blood pressure, risk of sub-endocardial myocardial ischaemia, exaggerated response to vasoactive agents, compromised organ blood flow, left ventricular diastolic dysfunction, and fluid balance issues.
The irreversible absence of normal brainstem functioning.
Several cranial nerve pathways integrating within the brainstem are tested, including the pupillary light reflex.
Because of the risk of severe hyperkalaemia.
ECG and electrolytes.
When there has been 5 minutes of cardiorespiratory arrest.
Ischaemic heart disease, peripheral vascular disease, cerebrovascular disease, and lung cancer.
In children, the head represents 18% of the surface area, and the lower limbs a smaller proportion.
Non-smokers: 0.3–2%, Smokers: 5–6%.
Raised jugular venous pressure, hepatomegaly, and peripheral oedema.
Maintain optimal organ perfusion, ventilation, hormone replacement (with vasopressin, T3, steroids, and insulin), and normal electrolyte status.
BSD equates to human death, as without brainstem function, higher cerebral activity and conscious perception are impossible.
The corneal reflex involves no reaction. The afferent pathway is via the ophthalmic branch of the trigeminal nerve (CN V) and the efferent pathway is via the facial nerve (CN VII).
An increase in expiratory airflow resistance.
Because burns patients may have other injuries such as head injury, fractures, or intra-abdominal injury, especially if they jumped out of a window to escape a fire.
Because of the presence of carboxyhaemoglobin (HbCO).
Preparations should be made to withdraw life support or, if the patient is being considered for organ donation, the transplant team will coordinate ongoing care until organ harvesting can take place.
The urgency of the surgery, the severity of the hypertension, and individual patient factors such as the extent and severity of end-organ damage and associated co-morbidities.
Non-heart-beating organ donation.
No response should be elicited. The afferent pathway is via the trigeminal nerve (CN V) and the efferent pathway is via the facial nerve (CN VII).
30 minutes.
It results in a reduction in FRC, leading to atelectasis, reduced pulmonary compliance, intra-operative and post-operative hypoxaemia, and increased risk of barotrauma.
Suspect cervical spine fractures and immobilize the patient using manual in-line immobilization or three-point fixation technique. Look for signs of inhalational injury and consider early endotracheal intubation.
To prevent sub-endocardial myocardial ischaemia due to a fall in coronary perfusion pressure or coronary filling time.
The ability to climb two flights of stairs without stopping.
Polycythaemia from chronic hypoxaemia.
30 mL of very cold saline is injected rapidly into each external auditory meatus to induce nystagmus. If the reflex pathway is intact, the eyes move towards the ipsilateral ear. In brainstem death, there are no eye movements. The afferent pathway is via the vestibulocochlear nerve (CN VIII) and the efferent pathway is via CN III and the abducens nerve (CN VI).
Poisoning due to inhalation of CO and cyanide is a significant risk.
Cigarette smoking.
Smoking cessation, optimal medical treatment, incentive spirometry, peri-operative chest physiotherapy, and early post-operative mobilisation.
High-flow, humidified O2 via face mask with a reservoir bag.
Dyspnoea at rest or on minimal exertion.
Active invasive cancer within 3 years (excluding non-melanoma skin cancer and brain tumours), haematological malignancy, untreated systemic infection, variant Creutzfeldt–Jakob disease, and HIV disease (though not necessarily infection).
Arrhythmias due to hyperkalaemia, hypoxia, hypoperfusion, or acidosis.
To assess risks such as shrapnel and blast injury from explosions, inhalational injury from enclosed spaces, and chemical burns which pose a risk to the medical team.
Increased total lung capacity (TLC), increased residual volume (RV), and increased functional residual capacity (FRC).
The time of injury guides fluid resuscitation.
To relieve restriction of ventilation or blood supply caused by circumferential burns.
10 minutes after death to ensure a safety margin.
That if the warm ischaemic time is prolonged, organ retrieval may not be possible; however, tissue and corneas may still be taken.
Superficial burns damage the epidermis, are erythematous and painful without blistering, and heal in 2-3 days.
To estimate the body surface area (BSA) involved in the burn.
The ongoing care focuses on optimising the condition of the organs while awaiting their retrieval.
FEV1 <1L, FEV1:FVC ratio <50%, and baseline type 2 respiratory failure.
2 hours.
Medical care should continue as before.
Check if the patient was on the organ donor register.
Partial or full-thickness burns greater than 10% of BSA in extremes of ages (less than 10 years or older than 50 years), partial or full-thickness burns greater than 20% of BSA in all other age groups, burns to face, hands, and genitals, significant chemical burns, electrical burns, or inhalational injury.
The transplant coordinators, as they are skilled at navigating the issues in this potentially delicate subject area.
Head 9%, arms 9% each, chest and abdomen 18%, back 18%, legs 18% each, perineum 1%.
The fact that the patient may be a potential organ donor must not influence decisions about their ongoing medical care.
Patients may need counseling and support to accept the events causing their injuries and the resulting disability or change in appearance.
GCS and pupil reactivity.
It improves peri-operative outcomes.
HbCO >40%, neurological symptoms or loss of consciousness, arrhythmias or myocardial infarction, pregnancy.
Increasing ambient temperature, covering exposed areas, using fluid warmers, and heated blankets.
Low Hb from blood loss, hyperkalaemia due to rhabdomyolysis, and raised urea and creatinine in impending or established renal failure.
Degree of respiratory compromise, current treatment regimen, respiratory physician’s clinic letters, and smoking history.
Paediatric burns charts.
Potential causes of rebound hypertension such as pain, hypoxia, hypercarbia, fluid overload, and hypothermia.
In air: 4–5 hours, In 100% oxygen: 1 hour, In hyperbaric oxygen at 3 atmospheres: 30 minutes.
It reduces peri-operative respiratory morbidity.
Rebound hypertension.
Ability to talk in full sentences, peripheral or central cyanosis, nicotine-stained fingernails, use of accessory respiratory muscles, evidence of right heart failure, and chest examination for crackles or wheeze.
The evidence supporting a reduction in overall peri-operative morbidity and mortality with regional anaesthetic techniques is mixed.
Increased daily calorie intake through nasogastric feeding and ulcer prophylaxis due to the risk of Curling’s ulcers.
The family must be consulted early and treated with respect and consideration throughout the process.
There is no upper or lower age limit for the donor.
Orthopaedic lower limb surgery (spinal anaesthesia) and upper abdominal and thoracic surgery (epidural analgesia).
Rising intracranial pressure causes brainstem ischaemia, bradycardia, and hypertension. Brainstem infarction leads to a surge in autonomic activity and catecholamine release ('sympathetic storm'), and hypothalamic–pituitary axis failure results in hormone level decline.
Diabetes insipidus, disseminated intravascular coagulation, cardiac ischaemia and arrhythmias, pulmonary oedema, metabolic acidosis, and hypothermia.
To depress any spinal reflexes that may occur during surgery, not due to concerns about awareness in the donor.
Call for senior assistance, have the difficult intubation trolley at hand, and keep the patient immobilized unless in a life-threatening 'can't intubate, can't ventilate' situation.
0–10%: None, 10–20%: Headache, malaise, 30–40%: Nausea, vomiting, impaired mental ability, 60–70%: Cardiovascular collapse and death.
Supplemental oxygen.
Due to impaired homeostasis, heat loss through burns, and resetting of the euthermic temperature to approximately 38.5°C.
Due to loss of the protective skin barrier and generalised immunosuppression.
Use of special wound dressings, topical antimicrobial agents, and possibly tetanus immunisation. Prophylactic antibiotics are not used routinely.
Partial thickness burns damage the epidermis and dermis, are painful with blisters, and heal in 10 days.
To maintain adequate cardiac output and minimize the risk of organ failure due to large fluid shifts and oedema.
CO poisoning causes hypoxia with elevated HbCO levels, while cyanide poisoning causes hypoxia with lactic acidosis and an increased anion gap.
Insertion of a urinary catheter with hourly urine output monitoring (aiming for at least 0.5 mL/kg/h) and daily renal function checks.
Full-thickness burns destroy the epidermis and dermis down to the subcutaneous fat, are white, leathery, painless, and heal slowly by wound contracture.
