Unklare Bewusstseinsstörung – könnte es eine Vergiftung sein?

Zusammenfassung

Bewusstseinsveränderungen sind eine typische Indikation für einen Notarzteinsatz. Dabei stellt das große Spektrum möglicher Differenzialdiagnosen für den Notarzt und die aufnehmende Klinik eine Herausforderung dar. Intoxikationen sind eine wichtige, jedoch insbesondere präklinisch oft schwierig zu identifizierende Ursache von Bewusstseinsveränderungen.

Abstract

An altered mental status is a common reason to dispatch a prehospital emergency physician in Germany. Intoxications belong to the top three differential diagnoses in this scenario, but the identification of the responsible toxin can be difficult. We describe the general approach to a patient with an altered mental status and suspected poisoning, specific hints to identify certain toxins preclinically as well as management strategies.

Schlüsselwörter

Unklare Bewusstseinsveränderung - Intoxikation - Vergiftung - Rettungsdienst - Notarzt

Key words

Unknown coma - intoxication - poisoning - prehospital management - EMS

• Literatur

• 1 Kanich W, Brady WJ, Huff JS. et al. Altered mental status: Evaluation and etiology in the ED. Am J Emerg Med 2002; 20: 613-617 doi:10.1053/ajem.2002.35464
• 2 Schmidt WU, Ploner CJ, Lutz M. et al. Causes of brain dysfunction in acute coma: a cohort study of 1027 patients in the emergency department. Scand J Trauma Resusc Emerg Med 2019; 27: 101 doi:10.1186/s13049-019-0669-4
• 3 Forsberg S, Höjer J, Enander C. et al. Coma and impaired consciousness in the emergency room: characteristics of poisoning versus other causes. Emerg Med J 2009; 26: 100-102 doi:10.1136/emj.2007.054536
• 4 Pohjola-Sintonen S, Kivistö KT, Vuori E. et al. Identification of drugs ingested in acute poisoning: correlation of patient history with drug analyses. Ther Drug Monit 2000; 22: 749-752 doi:10.1097/00007691-200012000-00016
• 5 Rasimas JJ, Sinclair CM. Assessment and management of toxidromes in the critical care unit. Crit Care Clin 2017; 33: 521-541 doi:10.1016/j.ccc.2017.03.002
• 6 Holstege CP, Borek HA. Toxidromes. Crit Care Clin 2012; 28: 479-498 doi:10.1016/j.ccc.2012.07.008
• 7 Parker-Cote JL, Rizer J, Vakkalanka JP. et al. Challenges in the diagnosis of acute cyanide poisoning. Clin Toxicol (Phila) 2018; 56: 609-617 doi:10.1080/15563650.2018.1435886
• 8 Yates C, Manini AF. Utility of the Electrocardiogram in drug overdose and poisoning: theoretical considerations and clinical implications. Curr Cardiol Rev 2012; 8: 137-151 doi:10.2174/157340312801784961
• 9 Liebelt EL, Francis PD, Woolf AD. ECG Lead aVR versus qrs interval in predicting seizures and arrhythmias in acute tricyclic antidepressant toxicity. Ann Emerg Med 1995; 26: 195-201 doi:10.1016/S0196-0644(95)70151-6
• 10 Boyle JS, Bechtel LK, Holstege CP. Management of the critically poisoned patient. Scand J Trauma Resusc Emerg Med 2009; 17: 29 doi:10.1186/1757-7241-17-29
• 11 Saitman A, Park H-D, Fitzgerald RL. False-positive interferences of common urine drug screen immunoassays: a review. J Anal Toxicol 2014; 38: 387-396 doi:10.1093/jat/bku075
• 12 Mikel C, Pesce AJ, Rosenthal M. et al. Therapeutic monitoring of benzodiazepines in the management of pain: current limitations of point of care immunoassays suggest testing by mass spectrometry to assure accuracy and improve patient safety. Clin Chim Acta 2012; 413: 1199-1202 doi:10.1016/j.cca.2012.03.017
• 13 Chan B, Gaudry P, Grattan-Smith TM. et al. The use of Glasgow Coma Scale in poisoning. J Emerg Med 1993; 11: 579-582
• 14 Turgut K, Yavuz E. Comparison of non-invasive CPAP with mask use in carbon monoxide poisoning. Am J Emerg Med 2020; 38: 1454-1457 doi:10.1016/j.ajem.2020.04.050
• 15 Masson R, Colas V, Parienti J-J. et al. A comparison of survival with and without extracorporeal life support treatment for severe poisoning due to drug intoxication. Resuscitation 2012; 83: 1413-1417 doi:10.1016/j.resuscitation.2012.03.028
• 16 Chyka PA, Seger D, Krenzelok EP. et al. Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43: 61-87
• 17 Benson BE, Hoppu K, Troutman WG. et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila) 2013; 51: 140-146 doi:10.3109/15563650.2013.770154
• 18 Ghannoum M, Hoffman RS, Gosselin S. et al. Use of extracorporeal treatments in the management of poisonings. Kidney Int 2018;
• 19 Arens AM, Kearney T. Adverse effects of physostigmine. J Med Toxicol 2019; 15: 184-191 doi:10.1007/s13181-019-00697-z
• 20 Anseeuw K, Delvau N, Burillo-Putze G. et al. Cyanide poisoning by fire smoke inhalation: a European expert consensus. Eur J Emerg Med 2013; 20: 2-9 doi:10.1097/MEJ.0b013e328357170b