Check List of Brain Death Determination for Comatose Patient on Ventilator
姓名____________年龄_____性别_____病历号__________床号_____
1.血压BP: _____／_____mmHg，脉搏P_____／min，体温T_____oC
2.昏迷量表Glasgow coma scale：眼球运动E_____，言语反应V_____，四肢运动M_____总分Total_____
3.深度昏迷发生时间Time of onset of deep coma_____(昏迷量表5分或5分以下)
4.开始使用呼吸器的时间Time when the ventilator was applied
5.昏迷原因Cause(s) of coma：(在相关的方格内打勾〝√〞，可复选Mark with〝√〞in the relevant box)
□神经外科手术Neurosurgery□头部外伤Head injury□蜘蛛膜下出血SAH
□脑出血Brain hemorrhage□脑梗塞Cerebral infarct□脑瘤Brain tumor
□脑脓肿Brain abscess□神经系统感染CNS infection□脑缺氧Hypoxia□低体温Hypothermia
□代谢性或内分泌障碍Metabolic or endocrine disturbance□药物中毒Drug intoxication
□其它Others (注明：___________________________________)□不明原因Unknown
6.检视下述征象，若有任何下述征象存在，记录其发生时间
Check the following signs, and when any of these signs are present, register the time of occurrence.
是 No 否 Yes 时间Time
(1)依赖人工呼吸器Depends on ventilator………□ □
无Absent有Present
(2)自发性运动Spontaneous movements……………□ □
(3)去皮质或去大脑之异常身体姿势Decorticate or decerebrate abnormal postures………□ □
(4)癫痫性抽搐Epileptic jerking…………………………… □ □
7.脑干反射测试Testing of brainstem reflexes
无Absent 有Present 不能确定U(原因R)
(1)头-眼反射Oculocephalic reflex………………………□ □ □( )
(2)瞳孔对光反射Pupillary light reflex…………………□ □ □( )
(3)眼角膜反射Corneal reflex………………………………□ □ □( )
(4)前庭-动眼反射Vestibulo-ocular reflex………………□ □ □( )
(5)对身体任何部位之疼痛刺激，在颅神经分布范围区内引起运动性反应Motor response within the cranial nerve distribution in response to adequate stimulation of any somatic area…□ □ □( )
(6)刺激支气管时之作呕或咳嗽反射Gag reflex or reflex response to the bronchial stimulation.□ □ □( )
主治医师签名Signature:
日期时间Date and Time: