Comprehensive observations and multidisciplinary approaches (COMA) in the management of unconscious patients: a prospective high fidelity simulation study - Liliane, N.; Tisljar, K.; Berger, S.; De Marchis, G. M.; Dittrich, T. D.; Bassetti, S.; Bingisser, R.; Hunziker, S.; Marsch, S.; Sutter, R. (J Neurol, 2025)
BACKGROUND: Managing patients with coma of unknown etiology presents a challenge requiring rapid, structured assessment. We aimed to examine how physicians from different specialties manage patients with coma of unknown etiology and adhere to recommendations in a highly standardized scenario. METHODS: Prospective high-fidelity simulation study conducted at an academic simulation center involving 50 physicians from acute care (38%), internal medicine (36%), and neurology (26%). Participants were confronted with a standardized coma scenario. Performance was assessed for adherence to expert-recommended clinical assessments (primary endpoints) and timing of interventions, such as airway protection, oxygen administration, toxicological screening, and self-evaluation (secondary endpoints). RESULTS: All participants recognized coma; 80% assessed the Glasgow Coma Scale, with 40% quantifying it correctly. 20% completed ABCDE assessments, with 66% performing head-to-toe examinations. Airway inspection was conducted by 89% of acute care physicians, 70% of neurologists, and 60% of internists. A median of 4 ancillary tests were ordered, mostly neuroimaging (98%) and toxicological screening (86%), while rare toxin screening (2%) and EEG (12%) were scarce. Oxygen was universally administered (100%), but treatment response was rarely checked (8%). Side-positioning for airway protection was infrequent (21% acute care, 15% neurology, 6% internal medicine), while intubation was more commonly ordered by internists (17%). Prior simulator training improved side-positioning rates (27% vs. 4%, p = 0.047). Self-evaluations showed high motivation (median 8/10) but moderate confidence (5/10). CONCLUSIONS: This study highlights specialty-specific differences, misconceptions, and gaps in managing coma of unknown etiology, including inconsistent diagnostic workup and missed treatments, emphasizing the need for guidelines, standardized care and training. REGISTRATION: ClinicalTrials.gov registry (ID NCT06265168).
Keywords: journalArticle; (8472/HEG-DSV), and the Swiss Society of General Internal Medicine (SSGIM). S; (ChatGPT-4omni, OpenAI, San Francisco, USA) was used to paraphrase and summarize; (Ref 10001C_192850/1 and 10531C_182422), the Bangerter-Rhyner Foundation; *Coma/therapy/diagnosis; *Simulation Training; *Unconsciousness/therapy/diagnosis; Adult; Bangerter-Rhyner-Stiftung; Berger reports no disclosures relevant to the manuscript. G.M. De Marchis was or; Coma; De Quervain research; Female; Fondazione Dr. Ettore Balli; Glasgow Coma Scale; Gottfried Julia Bangerter-Rhyner Foundation. He received personal grants from; Hospital Basel. S. Hunziker is supported by the Swiss National Foundation (SNF); Humans; Male; Marsch reports no disclosures relevant to the manuscript. R. Sutter received; Middle Aged; Neurocritical care; Prospective Studies; Prospective study; R. Bingisser is editor of medstandards.com, a symptom-based medical; Research Fund of the University Basel, the Scientific Society Basel, and the; Science Funds; Simulator study; Statement: The study has been approved by the appropriate local ethics committee; Swiss Heart Foundation, the science funds of the University Hospital Basel, and; Swiss Neurological Society; Swisslife Jubilaumsstiftung for Medical Research; Thermo Fisher GmbH. He received travel honoraria by Bayer and speaker; UCB-pharma and holds stocks from Alcon, Johnson & Johnson, Novartis, and Roche; Use of artificial intelligence-assisted technologies: The large language model; [Wissenschaftsfonds] of the University Hospital Basel and University of Basel; and Novo Nordisk. S. Bassetti reports no disclosures relevant to the manuscript; and have therefore been performed in accordance with the ethical standards laid; decision-support tool licensed to 150 European hospitals, owned by the University; down in the 1964 Declaration of Helsinki and its later amendments. All; further edited the content as needed and verified its accuracy. Ethical Standard; grant; holds shares from Johnson & Johnson, Roche, Lilly, Bristol-Myers Squibb, Merck,; honoraria by Medtronic and BMS/Pfizer. T.D. Dittrich was or is supported by the; is supported by the Swiss National Science Foundation; participants consented to participate in written form; research grants from the Swiss National Foundation (No 320030_169379), the; some of the manuscript's content. After using this application, the authors; the Research Fund for excellent young researchers of the University of Basel. He; the manuscript. K. Tisljar reports no disclosures relevant to the manuscript. S