The Comatose Patient

• Document GCS, pupils, brainstem reflexes, and motor pattern before any sedative; check glucose NOW.
• Focal signs or abnormal pupils point to CT; symmetric findings with preserved pupils point to a metabolic/tox workup.
• Never sedate an unexamined patient; carefully trial naloxone or flumazenil reversal as a diagnostic-therapeutic step.
• Meningismus/fever: antibiotics before LP when imaging must come first.

Prognosticating Coma After Anoxic Brain Injury

• Coma after cardiac arrest → first exclude major confounders (sedatives, neuromuscular blockers, hypothermia, metabolic derangement, shock)
• Never prognosticate before 72 h after ROSC (later if hypothermia or sedation) and never on a single sign — use a MULTIMODAL approach (ERC/ESICM 2021)
• ≥72 h after ROSC: pupillary AND corneal reflexes bilaterally absent?
• Poor-outcome criterion present
• SSEP N20 responses bilaterally absent?
• Poor-outcome criterion present
• Highly malignant EEG (suppressed background ± periodic discharges, or burst-suppression) off sedation?
• Poor-outcome criterion present
• Neuron-specific enolase >60 µg/L at 48–72 h (repeated and rising)?
• Poor-outcome criterion present
• Status myoclonus ≤72 h, or CT/MRI showing diffuse anoxic injury?
• Poor-outcome criterion present
• Two or more poor-outcome criteria present?
• Poor neurological outcome likely — discuss goals of care with the family in cautious, probabilistic language
• Indeterminate — continue full treatment and reassess daily
• Adapted from ERC/ESICM 2021 post-resuscitation prognostication: wait ≥72 h, use multimodal testing, require ≥2 criteria, and always account for confounders