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1、編號 Serial No. 腦死檢視表 Hospital _ Check List for Brain Death XXXX 醫院姓名 Name_ 年齡 Age_ 性別 Sex_病歷號碼 Record No._ 床號 Bed No._ 時間 Time 1._ 肛溫 T_OC 2._ 肛溫 T_OC 在相關的方格內打勾”V” Mark with “V” in the relevant box.第一次測試 First test再測試 Retest是 Yes否 No是 Yes否 No1.完全符合先決條件All the preconditions have been fulfilled. 2.排除可逆
2、性的昏迷All the exclusions have been made.無 Absent有 Present無 Absent有 Present3.確認無下列徵象Absence of the following signs ascertained(1)自發性呼吸 Spontaneous breathing.(2)異常姿勢，如去皮質或去大腦之姿勢 Abnormal postures,either decorticate or decerebrte.(3)癲癇性抽搐 Epileptic jerking 4.確認腦幹反射消失 Absence of brain stem reflexes ascert
3、ained(1)頭、眼反射 Oculocephalic relex.(2)瞳孔對光反射 Pupillary light reflex(3)眼角膜反射 Corneal reflex.(4)前庭、動眼反射 Vestibulo-ocular reflex.(5)對身體任何部位之疼痛刺激，在顱神經分佈區範圍內，引 起運動性反應Motor-response within the cranial nerve distribution in response to adequate stimulation of any somatic arca (6)氣管內插入導管刺激支氣管時，不能引起嘔咳之反射 Gag
4、reflexes or reflex response to bronchial stimulation by suction catheter passed down the trachea. 5.測試無自行呼吸 Testing of apnea測試前之血中氣體 Blood gas before apnea testPaCO2=_mmHg PaO2=_mmHg是 Yes否 No是 Yes否 No(1) 由人工呼吸器供應 100%氧氣 10 分鐘Preoxygenate with 100% oxygen for 10 minutes(2) 給予 95%氧氣加 5%二氧化碳 5 分鐘使動脈血中
5、PaCO2 in 95% oxygen for a further 5 minutes to ensure starting PaCO2 of 40mmHgPaCO2=_mmHg (PaO2=_mmHg)(3) 取除人工呼吸器，並由氣管內管供應 100%氧氣， 每分鐘供應 6 公升 Disconnect. Insufflate trachea with 100% oxygen at 6 L/min through intratracheal catheter passed to carina.(4)觀察 10 分鐘，並測試最後血中 CO2 濃度Maintain disconnection for 10 minutes and check final PaCO2PaCO2=_mmHg (PaCO2=_mmHg)(5) 確認病人無法自行呼吸Absolute apnea ascertained 簽名 Signature：
