• Sune Forsberg, Jonas Höjer, Ulf Ludwigs, and Harriet Nyström.
• Medical Intensive Care Unit, South Hospital, SE-118 83 Stockholm, Sweden.
• Am J Emerg Med. 2012 Nov 1;30(9):1986-90.

BackgroundPatients presenting unconscious may reasonably be categorized as suffering from a metabolic or structural condition.Study ObjectiveThe objective was to investigate if some routinely recorded clinical features may help to distinguish between these 2 main forms of coma in the emergency department (ED).MethodsAdults admitted to an ED in Stockholm between February 2003 and May 2005 with a Glasgow Coma Scale (GCS) score less than 11 were enrolled prospectively. The GCS score was entered into a protocol that was complemented with available data within 1 month.ResultsThe study population of 875 patients was classified into 2 main groups: one with a metabolic (n = 633; 72%) and one with a structural disorder (n = 242; 28%). Among the clinical features recorded in the ED, 3 were found to be strongly associated with a metabolic disorder, namely, young age, low or normal blood pressure, and absence of focal signs in the neurological examination. Patients younger than 51 years with a systolic blood pressure less than 151 mm Hg who did not display signs of focal pathology had a probability of 96% for having a metabolic coma. The mean GCS score on admission was identical in the groups. Hospital mortality was 14% in the metabolic and 56% in the structural group.ConclusionsThese findings indicate that unconscious young adults who present without a traumatic incident with a low or normal blood pressure and without signs of focal pathology most probably suffer from a metabolic disorder, wherefore computed tomography of the brain may be postponed and often avoided.Copyright © 2012 Elsevier Inc. All rights reserved.

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