Letters to the Editor
In Reply
We selected the term “Akute Vigilanzminderung” which is a German term for “acute impaired quantitative consciousness” (1). The more general term “impaired consciousness” is used in the emergency medical setting mostly to describe as a quantitative impairment of consciousness in the sense of the stages somnolence, stupor, and coma. But this is often not made explicit, and a distinction between quantitative and qualitative impairment of consciousness is made only in individual cases. The generally recognized CEDIS catalogue for lead symptoms in emergency medicine shows this lack of precision: the German option provided is an “altered state of consciousness”—no distinction is made between quantitative and qualitative impairment of consciousness. Reported “acute onset of impaired consciousness” can—as described by Prof. Moser—hide physiological processes that do not cause disease or psychiatric disorders that initially affect consciousness to an unknown degree—the more exact classification is the emergency physician’s task. Furthermore, the actual definition of consciousness is difficult and is the subject of philosophically controversial discussion. For this reason we think that the term “akute Vigilanzminderung” is correct for the purpose of communicating in the emergency setting in a scenario of impaired alertness in patients, which is also documented in the patient allocation/assignation codes of the German IVENA system used by the emergency services control center (at least in Bavaria). Anyhow, from the authors’ point of view, the most important factor is that communication between the different agents in emergency medicine functions successfully and that everyone knows what is being referred to—this should be the case for both terms, “akute Vigilanzminderung” [literally translated as “acute onset of impaired vigilance”] and “acute onset of (quantitative) impaired consciousness.” The simultaneous presence of several underlying causes in acute onset of impaired consciousness in patients is common in the emergency setting and was therefore emphasized in a way that is comprehensible in everyday language.
We can only support Prof. Chantelau’s comment regarding the relevance of diabetic coma in the sense of hypoglycemia or hyperglycemia. For this reason we explicitly pointed out in the chapter on initial ancillary studies that in all patients with acute onset of impaired vigilance/consciousness—independently of differential diagnostic considerations—certain basic ancillary studies should always be undertaken immediately, including measurement of blood glucose (1). This was later taken up again in the chapter on special aspects/metabolic/endocrine causes, where we described important symptoms in pathological changes of blood glucose concentrations. The list of red flag symptoms is not a complete summary of all possible warning signs of important disorders, but a subjective selection from the authors’ perspective. Symptoms occurring in hypoglycemia and hyperglycemia could have been included—but because we mentioned the necessity of initial blood glucose measurement in all patients with acute onset of impaired vigilance/consciousness, this did not happen. For reasons of a limited word count available for this article, we did not discuss therapeutic options in general.
DOI: 10.3238/arztebl.m2024.0206
On behalf of the authors
Prof. Dr. med. Matthias Klein
Zentrale Notaufnahme
Klinikum der Ludwig-Maximilians Universität (LMU)
München
Matthias.Klein@med.uni-muenchen.de
Conflict of interest statement
The authors of all contributions declare that no conflict of interest exists.
| 1. | Weiglein T, Zimmermann M, Niesen WD, Hoffmann F, Klein M: Acute onset of impaired consciousness: diagnostic evaluation in the emergency department. Dtsch Arztebl Int 2024; 121: 508–18 VOLLTEXT CrossRef MEDLINE PubMed Central |
