Zusammenfassung
Patienten, die wegen einer Bewusstseinsstörung in der Notaufnahme vorstellig werden, sind akut gefährdet. Ziel der ärztlichen Tätigkeit ist es, die Ursache der Bewusstseinsstörung rasch zu erkennen und eine zeitnahe Therapie einzuleiten. Das Management einer Bewusstseinsstörung ist vielschichtig und deshalb insbesondere in der Notaufnahme schwierig. In dieser Übersichtsarbeit wird ein Algorithmus vorgestellt, in dem die rasche Diagnostik und sofortige Therapie im Vordergrund stehen. Dies umfasst neben einer empirischen Erstdiagnostik und -therapie das systematische Herangehen bei der Diagnostik des bewusstseinsgestörten Patienten. Der verantwortliche Arzt in der Notaufnahme muss im Rahmen der Anamneseerhebung, der klinischen Untersuchung, der Laborbefunde und der bildgebenden Diagnostik seine Arbeitsdiagnose formulieren und zeitnah eine spezifische Therapie einleiten. Großer Wert muss v. a. auf die neurologische Untersuchung in der Notaufnahme gelegt werden. Zusammenfassend erlaubt – nach Stabilisierung der Vitalparameter – die rasche Erfassung der Ätiologie und die zielgerichtete, an der Ursache ausgerichtete Therapie einschließlich präventiver Maßnahmen, die Bedrohung einer irreversiblen Störung der zerebralen Funktion abzuwenden bzw. diese zu lindern.
Abstract
“Altered mental status” and “impaired level of consciousness” are general terms for the impairment of cerebral function, which is induced by local or diffuse cerebral pathologies. Patients with altered mental status presenting to the emergency department are at increased risk of irreversible brain damage and death. Thus, these patients constitute a diagnostic and therapeutic challenge. The major task of the emergency physician is to detect the reason for cerebral dysfunction and immediately start evidence-based treatment. The management of patients with an impaired level of consciousness is complex and difficult. In this review, an algorithm (“coma bundle”) is described, which supports the emergency room physician in the diagnosis and treatment of patients with altered mental status. After a prompt empirical diagnostic program and empirical treatment, a systematic approach for the diagnosis of altered mental status is recommended using the acronym “AEIOU TIPS”. After a thorough analysis of patient history, physical examination including a standardized neurological examination, laboratory results, and results of brain imaging, the working diagnosis is stated and evidence-based treatment is initiated. Common medical errors in the diagnosis and treatment of patients with altered mental status in the emergency department are premature establishment of a working hypothesis without proper examination and the use of time-consuming diagnostics leading to unnecessary delay of adequate treatment. In our opinion, a standardized neurological examination is fundamental for the diagnosis of patients with impaired mental status in the emergency department. In summary, after stabilization of vital parameters, rapid detection of the etiology of cerebral dysfunction is essential in order to start evidence-based treatment, which should also include preventive measures to avoid irreversible dysfunction of the brain.
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Christ, M., Popp, S. & Erbguth, E. Algorithmen zur Abklärung von Bewusstseinsstörungen in der Notaufnahme. Intensivmed 47, 83–93 (2010). https://doi.org/10.1007/s00390-009-0140-2
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DOI: https://doi.org/10.1007/s00390-009-0140-2