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As an alternative, the SDS should include a referral mechanism through which advice on treatment is available from a physician board-certified in medical toxicology.

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Hypoperfusion of the gastrointestinal tract, secondary to hypotension and/or splanchnic vasoconstriction, can slow absorption [17]. Enterohepatic recirculation may play a role in elimination of certain drugs.

When drug concentrations are available, the distribution of the drug into tissues may complicate the relationship between concentration and clinical effect.

In cases in which drug concentrations are not available but a specific drug is suspected, experts recommend waiting five half-lives prior to clinical determination of brain death [2].

To determine the extent to which inaccurate brain death determination by clinical testing may occur in this setting, we conducted a review of the literature in MEDLINE and SCOPUS using the search terms "brain death mimic" and "brain death drug overdose" for the dates January 1, 1960 to June 10, 2015.

A total of 1394 titles were reviewed for relevance to the topic, and only ten case reports of brain death mimicry were found (three baclofen [3, 4], two snake bites [5, 6], and one each of valproic acid [7], amitriptyline [8], mixed diazepam ethylene glycol [9], bupropion [10], and phorate [11], an organic phosphorous compound)."Evidenced-Based Guideline Update: Determining Brain Death in Adults" suggests that the clinician should exclude the presence of a central nervous system (CNS)-depressant drug effect by "history, drug screen, and calculation of clearance using five times the drug’s half-life." [2] However, there may be limitations to this approach.

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