Coma and brainstem death

The patient in a coma needs a rigorous clinical assessment that requires a meticulous approach to history-taking, and a systematic approach to the neurological examination. After immediate resuscitation and acute management, the clinician must establish the level of consciousness and seek evidence of meningism and localizing neurological signs. The prognosis depends on the underlying cause and the time taken to implement appropriate 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.