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  1. David Bates
  1. Dr David Bates, Department of Neurology, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK David.Bates{at}

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The assessment of patients in coma is a medical emergency. The cause should be identified and, where possible, corrected and the brain provided with appropriate protection to reduce further damage. It then becomes important to identify those patients for whom the prognosis is hopeless and in whom the institution or persistence of resuscitative measures is inappropriate, serving only to prolong the anguish of relatives and carers. It is frequently the neurologist to whom the physicians turn, to establish the prognosis of the individual in coma. It is therefore important that the neurologist in training develops a system whereby he or she can reasonably and accurately determine those factors which help in identifying prognosis and thereby provide reasonable advice to colleagues, paramedical staff, and the relatives and friends of the patient.


The advent of cardiopulmonary resuscitation during the 1960s, together with the advances in intensive care medicine, created the need for techniques to identify prognosis early in the course of coma. The fear that large numbers of patients resuscitated after drug overdose, trauma or anoxic injury might survive in a chronic vegetative state or that costly support would be wasted on patients who were insentient has resulted in more than 70 papers during the past 40 years attempting to develop clinical scales, electrophysiological techniques, imaging systems, and laboratory assays that predict the likely outcome in the individual patient.1-4 Regretfully, most of the reports on prognostic signs in coma include small numbers of patients, are retrospective or define outcome so poorly that adequate statistical validation is impossible. Few reports provide details of confidence limits for the specificity of individual tests, and the initial studies were almost invariably retrospective and identified length of coma or the lack of motor responses as indicative of a poor prognosis.

Factors that might be considered of …

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