All cases of falciparum malaria are potentially severe and life threatening, especially when managed inappropriately. A major reason for progression from mild through complicated to severe disease is missed or delayed diagnosis. Once diagnosed, the priority for treatment of complicated and severe disease is the parenteral administration of adequate, safe doses of an appropriate antimalarial, in the setting of the highest possible level of clinical care (i.e. usually an intensive care unit). Supportive management of complications such as coma, convulsions, metabolic acidosis, hypoglycaemia, fluid and electrolyte disturbances, renal failure, secondary infections, bleeding disorders and anaemia is also important. The most recent advance in antimalarial chemotherapy has been the use of artemisinin derivatives especially intravenous artesunate, which may well revolutionize the management of severe disease. Outside antimalarial therapy, mechanical ventilation and renal replacement have also played an important role in reducing mortality of this life-threatening condition.