Bewusstseinsstörungen aus toxikologischer Sicht

Zusammenfassung

Bewusstseinsstörungen durch absichtliche und unabsichtliche Vergiftungen sind ein häufiger Aufnahmegrund in Notaufnahmestationen deutscher Krankenhäuser. Zu den Erstmaßnahmen zählen die Sicherung von Vitalfunktionen und Atemweg, gefolgt von einer fokussierten Diagnostik bezüglich der Intoxikationsursache. Die Giftnotrufzentralen (GIZ) in Deutschland können wichtige Informationen zu spezifischen therapeutischen Maßnahmen liefern. Wichtige toxikologische Ursachen von Bewusstseinsstörungen sind Vergiftungen mit Opiaten, Benzodiazepinen, trizyklischen Antidepressiva, Alkohol, Methanol und Ethylenglykol, Kohlenmonoxid und Salicylaten. Im Vordergrund der Therapie stehen supportive Maßnahmen sowie die primäre und sekundäre Giftelimination. Für bestimmte Toxine gibt es eine spezifische Antidottherapie. Bei schweren Vergiftungen mit eingeschränkten Vitalfunktionen sollten Überwachung und Therapie auf einer Intensivstation erfolgen.

Abstract

Poisoning with impaired mental state is a frequent cause for hospital admission. The initial management includes assessment of vital functions and airway management followed by focussed diagnostics. Poison Emergency Centers can provide valuable assistance in acute intoxications. Clinically important agents causing mental state alterations include opiates, benzodiazepines, tricyclic antidepressants, alcohol, methanol and ethylene glycol, carbon monoxide and salicylates. Most important therapeutic measures comprise supportive care, decontamination or elimination. For certain toxins specific antidotes are available. In presence of severe intoxications and impaired vital functions, the patient should be transferred to the intensive care unit (ICU).

Schlüsselwörter

Intoxikation - Vergiftung - Bewusstseinsstörung - Antidot - Intensivstation - Giftelimination

Keywords

poisoning - mental state alteration - intoxication - antidote - ICU

• Literatur

• 1 Statistisches Bundesamt Deutschland. Tiefgegliederte Diagnosedaten der Krankenhauspatientinnen und -patienten (Datensatzstruktur). https://www.destatis.de/DE/Publikationen/Thematisch/Gesundheit/Krankenhaeuser/TiefgegliederteDiagnosedaten.html (letzter Zugriff: 21.6.2016)
• 2 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
• 3 Savitt DL, Hawkins HH, Roberts JR. The radiopacity of ingested medications. Ann Emerg Med 1987; 16: 331-339
• 4 Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med 1991; 20: 246-252
• 5 Kreshak AA, Cantrell FL, Clark RF et al. A poison center‘s ten-year experience with flumazenil administration to acutely poisoned adults. J Emerg Med 2012; 43: 677-682
• 6 Seger DL. Flumazenil--treatment or toxin. J. Toxicol Clin Toxicol 2004; 42: 209-216
• 7 Glauser J. Tricyclic antidepressant poisoning. Cleve Clin J Med 2000; 67: 704-719
• 8 Kerr GW, McGuffie AC, Wilkie S. Tricyclic antidepressant overdose: a review. Emerg Med J 2001; 18: 236-241
• 9 Pentel P, Benowitz N. Efficacy and mechanism of action of sodium bicarbonate in the treatment of desipramine toxicity in rats. J Pharmacol Exp Ther 1984; 230: 12-19
• 10 Hoffman JR, Votey SR, Bayer M et al. Effect of hypertonic sodium bicarbonate in the treatment of moderate-to-severe cyclic antidepressant overdose. Am J Emerg Med 1993; 11: 336-341
• 11 Madea B, Musshoff F. Knock-out drugs: their prevalence, modes of action, and means of detection. Dtsch Arztebl Int 2009; 106: 341-347
• 12 Mason PE. Gamma Hydroxybutyric Acid (GHB) Intoxication. Acad Emerg Med 2002; 9: 730-739
• 13 Thomson AD, Cook CCH, Touquet R et al. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke‘s encephalopathy in the accident and Emergency Department. Alcohol 2002; 37: 513-521
• 14 Müller D, Desel H. Ursachen, Diagnostik und Therapie häufiger Vergiftungen. Dtsch Arztebl Int 2013; 41: 690-700
• 15 Weaver LK, Hopkins RO, Chan KJ et al. Hyperbaric Oxygen for Acute Carbon Monoxide Poisoning. N Engl J Med 2002; 347: 1057-1067
• 16 Jüttner B. Carbon monoxide poisoning: Hyperbaric O2 therapy (HBOT) recommended. Anaesthesist 2016; 65: 299-300
• 17 Hadem J, Tacke F, Bruns T et al. Etiologies and outcomes of acute liver failure in Germany. Clin Gastroenterol Hepatol 2012; 10: 664-9.e2
• 18 Larsen FS, Schmidt LE, Bernsmeier C et al. High-volume plasma exchange in patients with acute liver failure: An open randomised controlled trial. J Hepatol 2016; 64: 69-78
• 19 Koch A, Trautwein C. N-acetylcysteine on its way to a broader application in patients with acute liver failure. Hepatology 2010; 51: 338-340
• 20 Botma M, Colquhoun-Flannery W, Leighton S. Laryngeal oedema caused by accidental ingestion of Oil of Wintergreen. Int J Pediatr Otorhinolaryngol 2001; 58: 229-232
• 21 Hill JB. Salicylate Intoxication. N Engl J Med 1973; 288: 1110-1113
• 22 Juurlink DN, Gosselin S, Kielstein JT et al. Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Ann Emerg Med 2015; 66: 165-181
• 23 Bora K, Aaron C. Pitfalls in salicylate toxicity. Am J Emerg Med 2010; 28: 383-384
• 24 Stolbach AI, Hoffman RS, Nelson LS. Mechanical ventilation was associated with acidemia in a case series of salicylate-poisoned patients. Acad Emerg Med 2008; 15: 866-869
• 25 Lee HL, Lin HJ, Yeh STY et al. Presentations of patients of poisoning and predictors of poisoning-related fatality: Findings from a hospital-based prospective study. BMC Public Health 2008; 8: 7
• 26 Brett AS, Rothschild N, Gray R et al. Predicting the Clinical Course in Intentional Drug Overdose: Implications for Use of the Intensive Care Unit. Arch Intern Med 1987; 147: 133-137
• 27 Benson BE, Hoppu K, Troutman WG et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol 2013; 51: 140-146
• 28 Curtis RA, Barone J, Giacona N. Efficacy of ipecac and activated charcoal/cathartic. Prevention of salicylate absorption in a simulated overdose. Arch Intern Med 1984; 144: 48-52
• 29 Neuvonen PJ, Vartiainen M, Tokola O. Comparison of activated charcoal and ipecac syrup in prevention of drug absorption. Eur J Clin Pharmacol 1983; 24: 557-562
• 30 Albertson TE, Derlet RW, Foulke GE et al. Superiority of activated charcoal alone compared with ipecac and activated charcoal in the treatment of acute toxic ingestions. Ann Emerg Med 1989; 18: 56-59
• 31 Duncan R, Thakore S. Position paper: whole bowel irrigation. J Emerg Med 2009; 37: 451-455
• 32 Manoguerra AS. Gastrointestinal decontamination after poisoning. Where is the science? Crit Care Clin 1997; 13: 709-725
• 33 Chyka PA, Seger D, Krenzelok EP et al. Position paper: Single-dose activated charcoal. Clin Toxicol 2005; 43: 61-87
• 34 Sato RL, Wong JJ, Sumida SM et al. Efficacy of superactivated charcoal administered late (3 hours) after acetaminophen overdose. Am J Emerg Med 2003; 21: 189-191
• 35 American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists. Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. J Toxicol Clin Toxicol 1999; 37: 731-751
• 36 Moll J, Kerns W, Tomaszewski C et al. Incidence of aspiration pneumonia in intubated patients receiving activated charcoal. J Emerg Med 1999; 17: 279-283
• 37 Prescott LF, Balali-Mood M, Critchley JA et al. Diuresis or urinary alkalinisation for salicylate poisoning?. Br Med J 1982; 285: 1383-1386
• 38 Roberts DM, Buckley NA. Enhanced elimination in acute barbiturate poisoning – a systematic review. Clin Toxicol 2011; 49: 2-12
• 39 Garella S. Extracorporeal techniques in the treatment of exogenous intoxications. Kidney Int 1988; 33: 735-754
• 40 Hampel G, Wiseman H, Widdop B. Acute poisoning due to hypnotics: the role of haemoperfusion in clinical perspective. Vet Hum Toxicol 1979; 21: 4-6
• 41 Teasdale G, Jennett B. Assessment Of Coma And Impaired Consciousness. Lancet 1974; 304: 81-84
• 42 Moeller KE, Lee KC, Kissack JC. Urine drug screening: practical guide for clinicians. Mayo Clin Proceed 2008; 83: 66-76