Comprehensive observations and multidisciplinary approaches (COMA) in the management of unconscious patients: a prospective high fidelity simulation study

TL;DR

This study examines how doctors from different specialties manage unconscious patients in a simulated setting, revealing gaps in care and adherence to guidelines.

Contribution

The study introduces a high-fidelity simulation approach to evaluate real-time decision-making in coma management across specialties.

Findings

Physicians showed inconsistent adherence to recommended assessments like Glasgow Coma Scale and ABCDE evaluations.

Specialty-specific differences were observed in airway management and diagnostic test ordering.

Prior simulator training improved some practices, but overall confidence and consistency remained low.

Abstract

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.

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).

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).

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.

ClinicalTrials.gov registry (ID NCT06265168).

The online version contains supplementary material available at 10.1007/s00415-025-13228-4.

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