If the ocular reflex exam cannot be trusted, move to ancillary testing rather than forcing an interpretation. The important question is whether the exam is valid enough to support a brain death evaluation.

For individuals 24 months of age or older, a minimum observation period of 24 hours is mandatory; Furthermore, your neuroimaging must match the profound severity of the clinical injury; Definitively establish a catastrophic, irreversible brain injury from a known mechanism that is fully capable of causing death by neurologic criteria; These evaluations must be performed by appropriately trained attending clinicians, or advanced practice providers where local institutional and state rules permit; If aggressive interventions were used to control elevated intracranial pressure, you must allow extra time to guarantee there is zero potential for functional recovery