Is the patient brain-dead?

CASE-REPORT A 45 year old male working as a labourer in the agricultural sector was brought to the emergency room with complaints of difficulty in opening the eye-lids, dysphagia, dysphonia, dyspnea, and progressive weakness in all four limbs, after awakening from sleep. At presentation, patient had no spontaneous respiratory efforts and was deeply cyanosed. Endotracheal intubation was performed immediately and the patient was mechanically ventilated. Physical examination revealed an afebrile patient with a heart rate of 130 beats/ minute and blood pressure of 160/100 mm Hg. He was comatose with absent motor responses to painful stimuli, complete ptosis, external, and internal ophthalmoplegia. Deep tendon reflexes and plantars were absent. Fang marks typical of snakebite were noted in the right middle finger. Patient was started on anti-snake venom (Haffkine Institute, Mumbai) at a dose of 100 mL stat followed by 50 mL at 6 hours, deep venous thrombosis and stress ulcer prophylaxis along with supportive care. Arterial blood gas analysis, serum electrolytes, liver, and renal function tests done were within normal limits. After initiation of ventilatory support, patient’s heart rate and blood pressure returned to normal limits, and he was maintaining normal oxygen saturation on pulse oximetry, however, there was no improvement in neurological status in the next 8 hours, and a possibility of brain death secondary to prolonged hypoxia prior to hospitalisation was being considered. Patient was unresponsive to tracheal suctioning; pupillary, corneal, and oculocephalic reflexes were absent and the cold caloric test was negative. However, approximately 12 hours after presentation, patient was noted to have triggered breaths on the ventilator and in the next 72 hours, patient had recovery of all the neurological functions. He was extubated and discharged with no neurological sequelae.