Evaluation of the accuracy of the Emergency Coma Scale: E-COMET STEP II


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American Journal of Emergency Medicine

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Evaluation of the accuracy of the Emergency Coma Scale: E-COMET STEP II?,??

To the Editor,

In 2002, Ohta and the Emergency Coma Scale Society began the de- velopment of a new coma scale, the Emergency Coma Scale (ECS), and established it the following year (Table 1) [1-3]. The ECS combines the advantages of the Glasgow Coma Scale (GCS) and the Japan Coma Scale (JCS). We predict that the ECS could achieve higher agreement and accuracy and has a sufficiently simple structure to be accepted by comedicals including nurses and paramedics. To prove these hypothe- ses, we designed a multicenter study called the “ECS Co-Operative Multi-center Evaluation Trial: E-COMET” [4]. E-COMET consists of 2 se- ries of trials, STEP I and STEP II. We have already reported on STEP I in 2011, in which the ECS, of all 3 scales, showed the highest agreement of scores among multiple raters [5,6]. As a next step, we attempted to prove the accuracy of the ECS on STEP II.

Medical students in the fourth and fifth grade at the University of To- yama participated in this trial. They attended lectures about the evalua- tion methods of the ECS, GCS, and JCS within their training period at the emergency department (ED) in our hospital. Participants watched videos of the simulated patients with Consciousness disturbance acted by ED physicians at Toyama University Hospital. We prepared 3 cases of different severities (Table 2). Each case had a correct scoring response for each of the 3 coma scales. After finishing the video, the participants evaluated the Conscious level of each case by 3 scales, and they input these data from the ECS Web site and these data were directory trans- ferred to our database at the Department of Crisis Medicine, University of Toyama. Data were analyzed with the statistical software Dr. SPSS II for Windows (SPSS, Inc, Chicago, IL). We calculated the weighted mean percentage of correct answers for the 3 coma scales and com- pared these results. We adopted the Wilcoxon Signed Rank Test as a test of average difference [7]. Data from 88 participants (54 data in the fourth and 34 data in the fifth grade students) were included in our sta- tistical analysis. Among all participants, the weighted mean percentage of correct answers showed a significantly higher score for the ECS (86.62 +- 14.35) (Wilcoxon signed rank test: JCS-ECS P = .01) than for the other 2 scales (Table 3). The weighted mean percentages of correct answers of the fourth grade students were significantly lower than those of the fifth grade students for all 3 scales. The tendency was par- ticularly significant for the GCS.

At our university, medical students usually start clinical training at the hospital in the fifth grade, when they examine patients for the first time, and their scores were higher than fourth grades. It seems that, to truly grasp any evaluation method, it is necessary to experience actual

? Funding sources: This trial was supported by the ECS Society, which is a joint commit- tee of the Japanese Congress on NeuroSurgical emergencies and the Japan Neurological Emergency Society.

?? Prior presentations: The Emergency Coma Scale for patients in the ED: concept, valid-

ity and simplicity. Am J Emerg Med. 2009; 27:240-3.A simple and useful coma scale for pa- tients with neurologic emergencies: the Emergency Coma Scale. Am J Emerg Med 2011; 29: 196-202.

patients with consciousness disturbance. Based on this assumption, Okudera et al [8] developed a simulation training course, the Immediate Stroke Life Support (ISLS) course, which aims to teach the management of patients with cerebrovascular diseases at emergency settings in Japan. The course is intended for all medical professionals and is now expanding throughout Japan. This course uses the ECS as a tool to eval- uate the consciousness level of patients with stroke.

This study elucidated that the ECS evaluation method is easy to un- derstand for beginners of evaluation by coma scales. We think that it may be effective to introduce the ECS to medical education, not only for nurses, medical students, and paramedics but also for citizens. If it is too difficult for citizens to fully understand the evaluation method of the ECS, the 3 major categories of the ECS are still very useful. The ECS is divided in 3 major categories, and they are defined solely accord- ing to the intensity of the stimulation which can wake patients and showed a strong correlation with the outcome of the patients with stroke and traumatic brain injury in our previous analyses [5,6].

The need for rapid and accurate diagnosis and treatment of patients with stroke and traumatic brain injury has been increasingly recognized in attempts to improve the quality of prehospital and inhospital medical services. Indeed, quick, accurate diagnosis and treatment often deter- mine the outcomes of these patients. We think that the unification of the coma scale among multiprofessionals may improve the efficiency in diagnosis and medical treatment and lead to improved patient outcomes.

From the results of both E-COMET STEP I and STEP II, we conclude that the ECS is extremely useful enough to spread widely in the treat- ment of neurologic emergencies.

We think that it is necessary to reassess the results for all raters after collecting additional data from physicians and nurses.


We thank our colleagues, Drs Takashi Asahi, Daisuke Tange, and Seisuke Okazawa, as well as the young physicians in training, and med- ical students in the ED of Toyama University Hospital.

Chiaki Takahashi, MD, PhD

Department of neurosurgery, National Hospital Organization Niigata

National Hospital, Kashiwazaki, Niigata, Japan Corresponding author at: Department of Neurosurgery National Hospital Organization Niigata National Hospital, 3-52

Akasaka-Cho, Kashiwazaki, Niigata, Japan Tel.: +81 257 22 2126; fax: +81 257 24 9812

E-mail address: [email protected]

Hiroshi Okudera, MD, PhD Masahiro Wakasugi, MD, PhD

Department of Crisis Medicine, Graduate School of Medicine University of Toyama, 2630 Sugitani, Toyama, Japan

0735-6757/(C) 2015

Table 1

The Emergency Coma Scale

invasive neurosurgery and multidisciplinary neurotraumatology. Tokyo: Springer- Verlag; 2006. p. 400-3.

[4] Takahashi C, Okudera H, Wakasugi M, Asahi T, Tange D, Okazawa S, et al. What is an

Category 1: The patients open their eyes, speak, and/or behave spontaneously (awake) and

1 can say correct date, place, and person

2 cannot say correct date, place, and person

Category 2: The patients can open their eyes, speak, and/or behave (aroused) by 10 speech

20 painful stimuli

Category 3: The patients can neither open their eyes nor speak by painful stimuli (not aroused) but respond with

100L localization

100W withdraw forearm with opened armpits 200F flex forearm with closed armpits

200E extend forearm with closed armpits

300 None

Table 2

Description about three simulated patients

3 cases with the consciousness disturbance

Case 1

63 years old, male

Consciousness disturbance represented with sudden vomiting after having given a large yawn at the meeting in a company, and a colleague called for an ambulance. He broke snoring without a response in painful stimuli at the emergency services arrival.

BP 210/140, HR 45/min, RR 18/min, irregular, pupil: anisocoria, light reflex: bilateral absent

This patient showed decorticate posture with painful stimuli. Answer: ECS 200 F, GCS E1V1M3, JCS 200

Case 2

68 years old, male

His wife noticed that he is abnormal vaguely and cannot speak fluently. Then, she took him to an outpatient clinic.

BP 126/72, HR 60/min, RR 16/min

This patient did not have any problems of orientation but said the same thing repeatedly and did not notice that there is the slight right hemiparesis.

Answer: ECS 1, GCS E4V5M6, JCS 1

Case 3

72 years old, male

His son found that he was lying on his back with consciousness disturbance when he got home. He called for an ambulance.

BP 180/100, HR 80, RR 15/min, pupil: isocoria, light reflex: bilateral prompt He opened his eyes and howls with painful stimuli and brushed the part

inflicted pain.

Answer: ECS 20, GCS E2V2M5, JCS 30

Abbreviations: BP, blood pressure, HR, heart rate, RR, respiratory rate.

Table 3

The mean percentage of correct answers of medical students

The mean percentage of correct answers +- SD

All raters

Fourth grade students

Fifth grade students


86.62 +- 14.34

80.08 +- 15.44

95.16 +- 6.84


72.96 +- 21.71

61.47 +- 21.79

86.50 +- 12.11


83.61 +- 11.04

82.72 +- 11.05

84.17 +- 11.33


  1. Ohta T. Transition of judgement on depth of consciousness disturbance and its perspectives–from the Japan Coma Scale to the Emergency Coma Scale. J Jpn Congr Neurol Emerg 2003;16:1-4.
  2. Okudera H, Ohta T, Aruga T, Ueda M, Uetsuhara K, Ohtaka H, et al. Development of an Emergency Coma Scale by the ECS task force: 2003 report. J Jpn Congr Neurol Emerg 2004;17:66-8.
  3. Wakasugi M, Okudera H, Ohta T, Asahi T, Igawa A, Tange D. Development of the new coma scale: Emergency Coma Scale (ECS). In: Kanno T, Kato Y, editors. Minimally

    excellent coma scale? Comparative study among JCS and ECS\\first report. Neurosurg Emerg 2007;12:129-35.

    Takahashi C, Okudera H, Sakamoto T, Aruga T, Ohta T. The Emergency Coma Scale for patients in emergency department–concept, validity and simplicity. Am J Emerg Med 2009;27:240-3.

  4. Takahashi C, Okudera H, Origasa H, Takeuchi E, Nakamura K, Fukuda O, et al. A simple and useful coma scale for patients with neurologic emergencies: the Emergency Coma Scale. Am J Emerg Med 2011;29:196-202.
  5. Wilcoxon F. Individual comparisons by ranking methods. Biometrics 1945;1:80-3.
  6. Okudera H, Wakasugi M, Hashimoto M, Sakamoto M, Berg BW, Ajimi Y, et al. Integrat- ed multi-modality simulation curriculum. Immediate Stroke Life Support. J Clin Sim Res 2013;2+3:38-42.

    Bougie-assisted tube thoracostomy placement: a novel technique?,??

    Tube thoracostomies (TT) are performed for a variety of indications including pneumothorax, hemothorax, and empyema. Studies have demonstrated complication rates ranging from 1.1% to 9.5%, depending upon the provider level of experience [1-5]. Complications can include incorrect tube placement, persistent air leaks, kinked tubing, and provider injury.

    The most commonly accepted technique involves insertion of a finger into the chest cavity with advancement of a Kelly clamped thoracostomy tube alongside the finger [6]. In 2010, Beer et al published a small study assessing the use of a bougie to facilitate placement of an endotracheal tube into the chest wall of a sheep with good success [7]. To the best of our knowledge, there have been no published case reports or studies discussing the full technique and success of a bougie-assisted TT approach. The purpose of this study was to assess the feasibility of this technique using a fresh human cadaver model.

    Two experts who have placed more than 50 TT and two senior residents who had placed more than 10 TT clinically prior to the study each performed one standard TT insertion and one bougie-assisted TT resulting in eight total placements. The insertions were with 36F thoracostomy tubes. The providers alternated which approach was per- formed first, serving as their own control. The bougie-assisted approach involved preloading the thoracostomy tube onto the bougie (See Figure), ad- vancing the bougie alongside the finger after entering the chest cavity, and then advancing the thoracostomy tube forward utilizing a Seldinger tech- nique (See Table). Two separate physicians confirmed intrathoracic place- ment by dissection and with ultrasound. All study data was recorded in real time by an experienced clinical research coordinator. The primary out- come was procedural time, which was measured from the first incision to the time when the provider was ready to suture the TT in place. Secondary outcomes included incision length, percentage correct intrathoracic place- ment, and complications.

    We performed eight total insertions with 100% intrathoracic place- ment with both approaches. Average procedure time was 48 seconds (95% CI, 15-81 seconds) for the standard technique and 40 seconds (95% CI, 16-65 seconds) for the bougie-assisted technique without sig- nificant differences between expert and senior resident subgroups. Of note, the mean incision length was 4.9 cm (95% CI, 3.2-6.5 cm) for the standard approach and 3.0 cm (95% CI 2.3-3.6 cm) for the bougie- assisted approach. There were no significant complications identified in this sample.

    To the best of our knowledge, this was the first study describing the feasibility of a bougie-assisted TT approach. The use of a bougie has been well-demonstrated in the emergency medicine literature for both bougie-assisted endotracheal intubation and bougie-guided cricothyrotomies [8,9]. Bougie-assisted TT was an additional use for

    ? Financial Support: None.

    ?? Meetings: None.

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