Page 5 - Ministerial Decree No. 550 of 2017 on the Declaration of Death

Positive vertical vestibulo-ocular reflex (notice the eye position for the head movement
direction)

Photo No. 1: Head and eyes are in a neutral position

Photo No. 2a and 3a: Eyes are squinting towards a direction opposite to the movement of the
head, if the movement is to the left or to the right side

Photo No. 2b and 3b: Eyes are returning back to the neutral position

The test is considered positive in case the eyes are moving towards the opposite direction of head
movement, and the brain stem is alive in this case and there is no need to complete the rest of the
tests. If the brain stem is dead, eyes and head will to the same direction.

This test should not be performed if it is suspected that a patient with a recent injury is suffering
from fractured vertebra, and the patient can be disconnected from the ventilator during the period
of the test for 20-30 seconds.

d. Vestibulo-ocular reflex (VOR) (thermal test):

It is performed through putting 50 ml of cold water at a temperature of 0°C in the external auditory
canal of the right and left ear alternately (for children: It is sufficient to put 10-20 ml). If no eye
movements occur, this means that there is brain death.

The absence of eye squint towards the direction of the test indicates a break in the reflex arc due
to damage to the reflex centers (the brain stem) or paralysis in the external eye muscles. Therefore,
this test should not be performed for a patient receiving muscle relaxants.

The integrity of the tympanic membrane (eardrum) must be checked by an otoscope before starting
the test, making sure that there is no mechanical obstruction in the auditory canal (cerumen/
earwax). In the event that the tympanic membrane is damaged, cold air can be used instead of cold
water, and this test should not be performed when there is local damage to the ear.

Figure No. (5) Thermal Test

e. Excitability of the upper and lower respiratory tract:

(For example: by sucking pharyngeal and tracheal secretions):

This test is performed to stimulate the pharynx and the carina of trachea. Insert the catheter for
sucking secretions from the pharynx and carina of trachea until it reaches the tracheal (Figure 6).
This test does not trigger any coughing or gagging reaction for the patient that has brain death.

*In case of any misinterpretation, the Arabic version of this legislation prevails.