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Background Identifying the cause of non-traumatic coma in the emergency department is challenging. The clinical neurological examination is the most readily available tool to detect focal neurological deficits as indicators for cerebral causes of coma. Previously proposed clinical pathways have granted the interpretation of clinical findings a pivotal role in the diagnostic work-up. We aimed to identify the actual diagnostic reliability of the neurological examination with regard to identifying acute brain damage. Methods Eight hundred and fifty-three patients with coma of unknown etiology (CUE) were examined neurologically in the emergency department following a predefined routine. Coma-explaining pathologies were identified retrospectively and grouped into primary brain pathology with proof of acute brain damage and other causes without proof of acute structural pathology. Sensitivity, specificity and percentage of correct predictions of different examination protocols were calculated using contingency tables and binary logistic regression models. Results The full neurological examination was 74% sensitive and 60% specific to detect acute structural brain damage underlying CUE. Sensitivity and specificity were higher in non-sedated patients (87/61%) compared to sedated patients (64%/59%). A shortened four-item examination protocol focusing on pupils, gaze and pyramidal tract signs was only slightly less sensitive (67%) and more specific (65%). Conclusions Due to limited diagnostic reliability of the physical examination, the absence of focal neurological signs in acutely comatose patients should not defer from a complete work-up including brain imaging. In an emergency, a concise neurological examination should thus serve as one part of a multimodal diagnostic approach to CUE.

Koma unklarer Genese („coma of unknown origin“, CUO) ist ein haufiges unspezifisches Notfallleitsymptom mit hoher Mortalitat. Die Diagnostik steht unter Zeitdruck bei einem gleichzeitig breiten Spektrum moglicher zugrunde liegender Erkrankungen mit ca. 50 % primaren ZNS-Pathologien und ca. 50 % extrazerebralen, fast ausschlieslich internistischen Ursachen. Trotz der mit dem Leitsymptom assoziierten hohen Mortalitat gibt es keine verbindlichen Leitlinien fur das Akutmanagement erwachsener CUO-Patienten. Wir schlagen einen interdisziplinaren Voralarm fur CUO-Patienten vor, wie wir ihn an unserem Klinikum der Maximalversorgung etabliert haben. Der Alarm wird anhand einfacher, aber fur die praklinische Identifikation von CUO ausreichender Triagekriterien bereits vor Eintreffen des Patienten ausgelost. Die fachliche Fuhrung liegt bei der Neurologie. Die Behandlungsroutine beinhaltet eine strukturierte Interaktion mit Pflege, innerer Medizin, Anasthesie, Radiologie (CT, CTA) und Labor (inkl. Liquor, Toxikologie) mit fakultativer Hinzuziehung von Neurochirurgie und Traumatologie. Die von uns erhobenen Daten sprechen fur ein standardisiertes leitsymptombasiertes diagnostisches Management, das die Neurologie und innere Medizin an den Anfang des diagnostischen Vorgehens stellt. Bildgebende Diagnostik sollte nicht nur abhangig von der klinisch-syndromalen Zuordnung erfolgen, weil Sensitivitat, Spezifitat und Interrater-Variabilitat Letzterer nicht ausreichen und mehrfache Pathologien, die auch einzeln CUO erklaren konnten, haufig sind. Klinische Untersuchung, Bildgebung und Laboruntersuchungen sollten als Bausteine eines integrativen diagnostischen Ansatzes gesehen werden, in dem die atiologische Zuordnung erst nach kompletter diagnostischer Aufarbeitung erfolgen sollte.

Background Coma of unknown origin is an emergency caused by a variety of possibly life-threatening pathologies. Although lethality is high, there are currently no generally accepted management guidelines. Methods We implemented a new interdisciplinary standard operating procedure (SOP) for patients presenting with non-traumatic coma of unknown origin. It includes a new in- house triage process, a new alert call, a new composition of the clinical response team and a new management algorithm (altogether termed “coma alarm”). It is triggered by two simple criteria to be checked with out-of-hospital emergency response teams before the patient arrives. A neurologist in collaboration with an internal specialist leads the in-hospital team. Collaboration with anaesthesiology, trauma surgery and neurosurgery is organised along structured pathways that include standardised laboratory tests and imaging. Patients were prospectively enrolled. We calculated response times as well as sensitivity and false positive rates, thus proportions of over- and undertriaged patients, as quality measures for the implementation in the SOP. Results During 24 months after implementation, we identified 325 eligible patients. Sensitivity was 60 % initially (months 1–4), then fluctuated between 84 and 94 % (months 5–24). Overtriage never exceeded 15 % and undertriage could be kept low at a maximum of 11 % after a learning period. We achieved a median door-to-CT time of 20 minutes. 85 % of patients needed subsequent ICU treatment, 40 % of which required specialised neuro- ICUs. Discussion Our results indicate that our new simple in-house triage criteria may be sufficient to identify eligible patients before arrival. We aimed at ensuring the fastest possible proceedings given high portions of underlying time-sensitive neurological and medical pathologies while using all available resources as purposefully as possible. Conclusions Our SOP may provide an appropriate tool for efficient management of patients with non- traumatic coma. Our results justify the assignment of the initial diagnostic workup to neurologists and internal specialists in collaboration with anaesthesiologists.