Coma and brainstem death

The diagnosis and management of the patient in coma demand rigorous clinical assessment, which encompasses a meticulous approach to history taking, the general medical and the neurological examination. Following immediate resuscitation and acute management, the level of consciousness must be characterized and evidence of meningism, brainstem or lateralizing neurological signs sought. The prognosis depends, not only on the underlying cause, but also on the appropriateness of the 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.