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Brain death is a clinical assessment. Despite established criteria for brain death determination, there are instances where confounding conditions create issues declaring death. Synthetic cannabinoids, cathinones, and phenethylamines have burst onto the recreational drug scene with the advertised advantage of undetectable use with standard drug testing. This has created challenging scenarios where the toxin is unidentifiable and the clinical effects are not predictable.

An unidentified 25-year-old man was brought to the hospital by EMS after being found down at a music festival. He developed clinical seizures requiring treatment for status epilepticus. There was no evidence of trauma, infarct, hemorrhage, or detectable toxins that explained his presentation. Brain MRI demonstrated extensive cortical diffusion restriction. His ICU course was complicated by rapid liver failure requiring evaluation for liver transplant, however he was not a candidate. Administrative DNR was reversed when his family was identified via social media and subsequently requested evaluation for organ donation, necessitating brain death declaration for advancement. Prolonged midazolam infusion was administered for seizure-like activity. Given his electrolyte disturbances and inability to clear midazolam due to liver failure, clinical examination was insufficient to declare brain death and the patient required ancillary testing. A nuclear medicine scan was conducted and found to be consistent with absence of cerebral activity. On a brainstem evaluation several hours later, the patient was observed to have nystagmus with cold caloric testing before it finally extinguished and brain death was declared.

Brain death requires only a clinical exam and history consistent with catastrophic brain injury.  Guidelines require the patient to be free of temperature and electrolyte abnormalities that often occur secondary to intoxication. There are rare cases when usual criteria cannot be met and supportive tests are not perfect measures to declare brain death. New synthetic drugs may increase these complicated clinical situations.