KENTUCKY

FRIED

GALLUS

It's just not something they can determine initially.

Life After Death

When a person dies, their cells don't all stop functioning simultaneously. In fact some, like the large cells in this tissue from a human brain, even start growing and activating genes. These so-called 'zombie cells' are a type of immune cell called glia, and researchers have discovered that, for many hours after death – defined in this experiment as the point when a section of living brain tissue was removed during surgery – the cells ramp up gene activity, grow in size and extend protrusions into surrounding tissue. While it’s not entirely surprising that immune cells, whose job it is to clear up tissue damage, become activated in this way, the specific details and time-frames of such postmortem changes had not previously been recorded. For neurologists studying brain pathologies, the data is likely to be a valuable resource for helping to distinguish normal postmortem events from those caused by a disease.

Written by Ruth Williams

Image from work by Fabien Dachet and colleagues, Dr Jeffrey Loeb's lab, University of Illinois

University of Illinois at Chicago, Chicago, IL, USA

Image copyright held by the original authors

Research published in Scientific Reports, March 2021

I was told I had to choose topics, or else my classmate would choose them for me... so, fine. Sighs. I chose three and thus am now extra-reading up on: 

symptoms and surgical treatment of chronic pancreatitis 

classification of skull fractures

determination of brain death

I chose this last one because two weeks ago, I stood beside a paramedic as she went through the steps for a fresh ED admit ... and I realized I didn’t even know what things to check before someone could be declared brain dead. In fact, I always confused the ideas of comatose, brain death and persistent vegetative state. So I’ll clear it up for myself (and perhaps others?): 

BRAIN DEATH: a state of irreversible unconsciousness (GCS 1-1-1) which meets very strict criteria. Importantly, there is an absence of brainstem reflexes, motor response, and respiratory drive. There are many other criteria as well, but for starters, the reflexes to check are the following: 

1. corneal reflex (CN V1 + CN VII)  2. oculocephalic reflex (CN VIII + CN III and CN VI) 3. gag reflex (CN IX + CN X)  4. pupillary light reflex (CN II + CN III) 5. cough reflex (CN X + CN X)  6. pain reflex (CN V + CN VII)

Because the determination of brain death is so crucial to get right, there are other criteria as well, which are explained really well on teachmesurgery.com (linked the article here). These include that the patient not be on sedatives, be apneic, have no reversible causes in the background, and many more.

Brain death differs from persistent vegetative state, although both are in an irreversible unconscious state. A patient who is brain dead cannot breathe on their own. A person in a vegetative state actually does breathe on their own. A comatose patient is also unconscious, with no reflexes, but they may be awakened -- it depends on the cause of the coma.

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In the case of the patient on that fateful day, the presentation was GCS 1-1-1, and she was intubated in the field. The husband called the ambulance because the patient had a seizure while sitting on the toilet. The toilet... yes, you guessed right. When we did a CT of her head, there was a very large subarachnoid hemorrhage. It’s a textbook case: undiagnosed cerebral aneurysm ruptures in the background of straining (i.e. being on the toilet), and if the bleed is large enough, it can be fatal. 

In her case, it was. However, you need to wait 5-6 hours to declare someone braindead, so we observed her in our ED while the family came to say goodbye. She was young... 50-something? ... and no significant medical history except smoking.

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Anyway, look at the cute new mask I made.