Coma and brainstem death

The diagnosis and management of the patient in coma demands rigorous clinical assessment that encompasses a meticulous approach to history-taking and systemic and neurological examination. Following immediate resuscitation and acute management, the level of consciousness must be assessed and evidence of meningism, brainstem or lateralizing neurological signs sought. The prognosis depends on the underlying cause and the appropriateness of acute management. The diagnosis of brain death depends on establishing the aetiology of irreversible brain damage, excluding reversible causes and establishing the absence of any brainstem reflexes.