The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness
Abstract Background Management of patients with coma of unknown etiology (CUE) is a major challenge in most emergency departments (EDs). CUE is associated with a high mortality and a wide variety of pathologies that require differential therapies. A suspected diagnosis issued by pre-hospital emergen...
| Main Authors: | , , , , , |
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| Format: | Article |
| Language: | English |
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BMC
2021-01-01
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| Series: | Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s13049-020-00822-w |
| _version_ | 1818668437217476608 |
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| author | Maximilian Lutz Martin Möckel Tobias Lindner Christoph J. Ploner Mischa Braun Wolf Ulrich Schmidt |
| author_facet | Maximilian Lutz Martin Möckel Tobias Lindner Christoph J. Ploner Mischa Braun Wolf Ulrich Schmidt |
| author_sort | Maximilian Lutz |
| collection | DOAJ |
| description | Abstract Background Management of patients with coma of unknown etiology (CUE) is a major challenge in most emergency departments (EDs). CUE is associated with a high mortality and a wide variety of pathologies that require differential therapies. A suspected diagnosis issued by pre-hospital emergency care providers often drives the first approach to these patients. We aim to determine the accuracy and value of the initial diagnostic hypothesis in patients with CUE. Methods Consecutive ED patients presenting with CUE were prospectively enrolled. We obtained the suspected diagnoses or working hypotheses from standardized reports given by prehospital emergency care providers, both paramedics and emergency physicians. Suspected and final diagnoses were classified into I) acute primary brain lesions, II) primary brain pathologies without acute lesions and III) pathologies that affected the brain secondarily. We compared suspected and final diagnosis with percent agreement and Cohen’s Kappa including sub-group analyses for paramedics and physicians. Furthermore, we tested the value of suspected and final diagnoses as predictors for mortality with binary logistic regression models. Results Overall, suspected and final diagnoses matched in 62% of 835 enrolled patients. Cohen’s Kappa showed a value of κ = .415 (95% CI .361–.469, p < .005). There was no relevant difference in diagnostic accuracy between paramedics and physicians. Suspected diagnoses did not significantly interact with in-hospital mortality (e.g., suspected class I: OR .982, 95% CI .518–1.836) while final diagnoses interacted strongly (e.g., final class I: OR 5.425, 95% CI 3.409–8.633). Conclusion In cases of CUE, the suspected diagnosis is unreliable, regardless of different pre-hospital care providers’ qualifications. It is not an appropriate decision-making tool as it neither sufficiently predicts the final diagnosis nor detects the especially critical comatose patient. To avoid the risk of mistriage and unnecessarily delayed therapy, we advocate for a standardized diagnostic work-up for all CUE patients that should be triggered by the emergency symptom alone and not by any suspected diagnosis. |
| first_indexed | 2024-12-17T06:36:18Z |
| format | Article |
| id | doaj.art-a2f488aee492418d9273663c63d2513c |
| institution | Directory Open Access Journal |
| issn | 1757-7241 |
| language | English |
| last_indexed | 2024-12-17T06:36:18Z |
| publishDate | 2021-01-01 |
| publisher | BMC |
| record_format | Article |
| series | Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine |
| spelling | doaj.art-a2f488aee492418d9273663c63d2513c2022-12-21T22:00:00ZengBMCScandinavian Journal of Trauma, Resuscitation and Emergency Medicine1757-72412021-01-012911910.1186/s13049-020-00822-wThe accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousnessMaximilian Lutz0Martin Möckel1Tobias Lindner2Christoph J. Ploner3Mischa Braun4Wolf Ulrich Schmidt5Department of Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of HealthDepartment of Emergency Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of HealthDepartment of Emergency Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of HealthDepartment of Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of HealthDepartment of Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of HealthDepartment of Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of HealthAbstract Background Management of patients with coma of unknown etiology (CUE) is a major challenge in most emergency departments (EDs). CUE is associated with a high mortality and a wide variety of pathologies that require differential therapies. A suspected diagnosis issued by pre-hospital emergency care providers often drives the first approach to these patients. We aim to determine the accuracy and value of the initial diagnostic hypothesis in patients with CUE. Methods Consecutive ED patients presenting with CUE were prospectively enrolled. We obtained the suspected diagnoses or working hypotheses from standardized reports given by prehospital emergency care providers, both paramedics and emergency physicians. Suspected and final diagnoses were classified into I) acute primary brain lesions, II) primary brain pathologies without acute lesions and III) pathologies that affected the brain secondarily. We compared suspected and final diagnosis with percent agreement and Cohen’s Kappa including sub-group analyses for paramedics and physicians. Furthermore, we tested the value of suspected and final diagnoses as predictors for mortality with binary logistic regression models. Results Overall, suspected and final diagnoses matched in 62% of 835 enrolled patients. Cohen’s Kappa showed a value of κ = .415 (95% CI .361–.469, p < .005). There was no relevant difference in diagnostic accuracy between paramedics and physicians. Suspected diagnoses did not significantly interact with in-hospital mortality (e.g., suspected class I: OR .982, 95% CI .518–1.836) while final diagnoses interacted strongly (e.g., final class I: OR 5.425, 95% CI 3.409–8.633). Conclusion In cases of CUE, the suspected diagnosis is unreliable, regardless of different pre-hospital care providers’ qualifications. It is not an appropriate decision-making tool as it neither sufficiently predicts the final diagnosis nor detects the especially critical comatose patient. To avoid the risk of mistriage and unnecessarily delayed therapy, we advocate for a standardized diagnostic work-up for all CUE patients that should be triggered by the emergency symptom alone and not by any suspected diagnosis.https://doi.org/10.1186/s13049-020-00822-wComaDiagnostic errorsDiagnostic accuracyEmergency medical servicesDisorder of consciousness |
| spellingShingle | Maximilian Lutz Martin Möckel Tobias Lindner Christoph J. Ploner Mischa Braun Wolf Ulrich Schmidt The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine Coma Diagnostic errors Diagnostic accuracy Emergency medical services Disorder of consciousness |
| title | The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness |
| title_full | The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness |
| title_fullStr | The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness |
| title_full_unstemmed | The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness |
| title_short | The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness |
| title_sort | accuracy of initial diagnoses in coma an observational study in 835 patients with non traumatic disorder of consciousness |
| topic | Coma Diagnostic errors Diagnostic accuracy Emergency medical services Disorder of consciousness |
| url | https://doi.org/10.1186/s13049-020-00822-w |
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