An acute manifestation of metabolic disorders in diabetes, hyperglycemic coma, can be fatal. About 4% of deceased diabetic patients under the age of 50 suffered from this severe complication of diabetes. It is not uncommon for children and adolescents to be diagnosed with diabetes only after they have passed out in the hospital. Timely and competently provided assistance will save the life of a diabetic, and properly organized treatment of a patient with diabetes will allow him to avoid this serious condition.

With insufficient utilization of glucose in the body, its concentration in the blood increases sharply. This condition is called hyperglycemia, it is characterized by 3 stages:

• Light,<10 ммоль/л;
• Average, from 10 to 16 mmol/l;
• Severe, >16 mmol/l.

If, at a severe stage, sugar is not stabilized at an acceptable level, a diabetic coma (hyperglycemic coma) may develop in a diabetic.

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In diabetes, hyperglycemia acquires a chronic form; in the insulin-dependent form of the disease, it is associated with insufficient intake of “external” (exogenous) insulin. For patients with type 2 diabetes, the accumulation of glucose in the blood is caused by a decrease in the sensitivity of tissues to insulin and, sometimes, with insufficient production of their own insulin.

Causes

A high concentration of glucose in the blood can be caused by several reasons:

• Overeating, eating high carbohydrate foods;
• Taking certain medications (antidepressants, beta-blockers, corticosteroids);
• stressful situation;
• Insulin infusion disorders in type 1 diabetes.

The body in a state of stress tries to provide itself with easily digestible “’ power engineer”- glucose, triggering the mechanisms for converting internal glycogen stores.

Stressful situations include:

• Fasting (more than 8 hours);
• Psycho-emotional overstrain (exams, domestic conflicts, etc.);
• Physical overload;
• Pregnancy;
• childbirth;
• Diseases caused by infection;
• inflammatory processes.

For a healthy person, a “jump” in blood sugar is not dangerous; in a diabetic with impaired carbohydrate metabolism, hypoglycemia is highly undesirable.

Most often, hypoglycemic coma, diagnosed in patients with type 1 diabetes, is associated with incorrect actions during insulin injections:

• missed dose;
• Incorrectly chosen dose;
• Low-quality insulin is used;
• The drug has been replaced (another manufacturer, etc.).

In patients with type 2 diabetes, diabetic coma is less common, it can be provoked by factors such as:

• Cancellation of sugar-lowering drugs;
• Violation of the diet;
• Suppression of the production of own insulin, caused by damage to the pancreas.

Alcohol consumed by a diabetic can lead to the development of a hyperglycemic coma.

Clinical picture

The disease develops slowly, from several hours to several days. During this time, the patient clearly shows symptoms - signs of a diabetic coma. If no action is taken, precoma will occur, and then the patient will fall into an unconscious state. Staying in this state for more than a day without medical assistance in a hospital will lead to death.

According to statistics, hyperglycemic coma rarely develops in diabetics in old age. It is also rarely recorded in patients with type 2 diabetes. The most at risk are children and adolescents, who are characterized by a state of mental and hormonal instability. Often it is gross deviations from the diet in children who are not controlled by their parents that lead to an attack.

30% of diabetic patients were first diagnosed while they were in precoma.

Signs of a diabetic coma

Gradual dehydration of the body and intoxication caused by a high concentration of glucose in the blood externally manifest itself as follows:

• Increasing everlasting thirst;
• Increased urination (at the beginning of the process);
• Cessation of urination (in a state of precoma);
• headache;
• Abdominal pain, vomiting, nausea;
• Diarrhea, constipation (precoma);
• weakness;
• Reduced blood pressure (precoma);
• Low temperature (precoma);
• Dryness of the skin;
• redness of the face;
• Tachycardia (precoma);
• Decreased muscle tone;
• Noisy breathing with the smell of acetone (precoma).

Hyperglycemic coma is a complication of the "sweet illness" of an acute nature, accompanied by high blood sugar levels against the background of absolute (with type 1 disease) or relative (with type 2) insulin deficiency.

The condition is considered critical and requires immediate hospitalization and intervention of specialists. The emergency care algorithm for hyperglycemic coma should be known to everyone who suffers from diabetes or has sick friends and relatives.

Coma differentiation

Since there are three different types of hyperglycemic coma, the assistance provided at the medical stage is different for each of them:

• ketoacidotic coma;
• hyperosmolar coma;
• lactic acidosis.

Ketoacidosis is characterized by the formation of ketone bodies (acetone) and develops against the background of insulin-dependent diabetes mellitus. The hyperosmolar state occurs in type 2 disease, ketone bodies are absent, but patients suffer from high sugar levels and significant dehydration.

Lactic acidosis is characterized by moderate glycemia in comparison with the first two pathologies, develops with non-insulin dependent diabetes and is characterized by the accumulation of a significant amount of lactic acid in the blood.

Clinic

Symptoms of ketoacidosis and hyperosmolar coma are similar. The clinical picture grows gradually. There is excessive thirst, copious urine output, bouts of nausea and vomiting, convulsions.

The difference that allows differentiating these two conditions is the presence of a specific smell of acetone coming from the mouth in ketoacidosis and its absence in the hyperosmolar state.

In addition, at home, you can clarify the sugar level (with hyperosmolar coma, it can reach 40 mmol / l and above, with ketoacidosis - 15-20 mmol / l) and determine the presence of acetone bodies in the urine using test express strips.

Determination of the level of acetone in the urine is one of the criteria for differentiating the types of hyperglycemic coma

Excessive thirst and polyuria are not typical for lactic acidosis, there are no ketone bodies in the urine. At home, it is almost impossible to diagnose.

First aid

For any type of hyperglycemic coma, you should immediately call an ambulance and, before their arrival, perform a series of sequential measures. First aid is as follows:

• Lay the patient in a horizontal position.
• Provide fresh air, unbutton or remove outer clothing. If necessary, remove the tie, belt.
• Turn the patient's head to one side so that in the event of an attack of vomiting, the person does not choke on vomit.
• Control the position of the tongue. It is important that there is no sinking.
• Find out if the patient is on insulin therapy. In case of a positive answer, create the necessary conditions for him to make an injection on his own or help him inject the hormone in the required dosage.
• Control blood pressure and pulse. If possible, record the indicators in order to report them to the ambulance specialists.
• If the patient is "cowardly", warm him up by covering him with a blanket or providing a warm heating pad.
• Drink enough.
• In case of cardiac or respiratory arrest, resuscitation is necessary.

Features of resuscitation

Resuscitation should be started in adults and children, without waiting for the arrival of ambulance specialists, when symptoms appear: no pulse in the carotid arteries, no breathing, the skin becomes gray-bluish, the pupils are dilated and do not respond to light.

1. Lay the patient on the floor or other hard, flat surface.
2. Tear or cut outer clothing to provide access to the chest.
3. Tilt the patient's head as far back as possible, put one hand on the forehead, and push the patient's lower jaw forward with the other. This technique ensures the patency of the airways.
4. Make sure that there are no foreign bodies in the mouth and throat, if necessary, quickly remove the mucus.

Compliance with the rules of resuscitation is a step towards its successful completion

Breathing "mouth to mouth". A napkin, gauze cut or handkerchief is placed on the patient's lips. A deep breath is taken, the lips are pressed tightly against the patient's mouth. Then a strong exhalation is carried out (for 2-3 seconds), while closing the nose of a person. The effectiveness of artificial ventilation can be seen by raising the chest. The frequency of breaths is 16-18 times per minute.

Indirect cardiac massage. Both hands are placed on the lower third of the sternum (approximately in the center of the chest), becoming on the left side of the person. Conduct vigorous pushes towards the spine, shifting the surface of the chest by 3-5 cm in adults, 1.5-2 cm in children. The frequency of pressing is 50-60 times per minute.

When combining mouth-to-mouth breathing and heart massage, as well as carrying out activities by one person, it is necessary to alternate 1 breath with 4-5 chest compressions. Resuscitation is carried out until the arrival of ambulance specialists or until signs of life appear in a person.

Important! If the patient has regained consciousness, in no case leave him alone.

Medical stage

After the arrival of specialists, the patient's condition is stabilized, he is subject to hospitalization in the intensive care unit. Emergency care for hyperglycemic coma at the medical stage depends on the type of condition that has developed in a patient with diabetes mellitus.

Hospitalization of the patient is a prerequisite, even in the case of normalization of the condition at home

Ketoacidotic coma

A prerequisite is the introduction of insulin. First, it is administered in a stream, then intravenously drip on 5% glucose to prevent the appearance of a hypoglycemic state. The patient is given a gastric lavage and the intestines are cleansed with a 4% bicarbonate solution. Intravenous administration of saline, Ringer's solution to restore fluid levels in the body, and sodium bicarbonate is indicated to restore lost electrolytes.

Important! Blood pressure and blood glucose levels are constantly monitored. The level of glycemia is reduced gradually so that it is not critical for the patient.

To support the work of the heart and blood vessels, glycosides, Cocarboxylase are used, oxygen therapy is carried out (saturation of the body with oxygen).

Hyperosmolar state

Emergency care for this coma has certain differences:

• a significant amount of infusion preparations is used (up to 20 liters per day) to restore the level of fluid in the body (saline solution, Ringer's solution);
• insulin is added to the physiology and administered by drip so that the sugar level decreases slowly;
• when glucose levels reach 14 mmol / l, insulin is administered already at 5% glucose;
• bicarbonates are not used because there is no acidosis.

Infusion therapy is an important stage of emergency medical care

lactic acidosis

Features of relief of lactic acid coma are as follows:

• drip into a vein is injected with methylene blue, which allows you to bind hydrogen ions;
• the introduction of Trisamine;
• performing peritoneal dialysis or hemodialysis to purify the blood;
• intravenously drip sodium bicarbonate;
• small doses of insulin infusion on 5% glucose as a preventive measure for a sharp decrease in the quantitative indicators of blood glucose.

Knowing how to properly provide first aid for a hyperglycemic condition, as well as having the skills to conduct resuscitation, can save someone's life. Such knowledge is valuable not only for patients with diabetes, but also for their relatives and friends.

A life-threatening complication of diabetes mellitus, in which there is a sharp jump in blood sugar towards an increase, is called hyperglycemic coma. Pathology often progresses in type 1 diabetes mellitus, however, in advanced cases, diabetics diagnosed with type 2 can get a complication. In the event of the development of signs of hyperglycemic coma and a sharp deterioration in well-being, first aid is considered important, the correct provision of which will save the health and life of the patient.

Causes of pathology

The hyperglycemic state most often develops in patients with advanced and complicated form of diabetes mellitus, and the disease lasts for quite a long time. In this case, the etiology and pathogenesis of the development of such a condition is often unknown, the patient risks getting dangerous complications, even death. Other reasons why coma develops are:

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• unbalanced diet;
• long breaks between meals;
• excessive physical overload;
• dehydration of the body;
• disruption of the digestive system;

If a person has been diagnosed with "diabetes mellitus", he must have the idea that due to non-compliance with the rules and prescriptions of the doctor, a diabetic coma occurs. At the same time, there is not only hyperglycemic, but also hypoglycemic coma, the reasons for the development of which are directly opposite - the patient's blood sugar falls below the vitally acceptable limits.

Varieties

Pathology is characterized by the fact that it has 3 stages of development. Below is a comparative table, having studied which you can navigate in the event of a sharp deterioration in the well-being of a loved one with diabetes:

There is transient hyperglycemia, which occurs with the abuse of carbohydrate-containing foods and sugar. It occurs even in people who do not have diabetes.

Crisis Development Mechanism

This condition leads to a sharp increase in glucose.

Hyperglycemic crisis develops in this order:

1. The hormone does not penetrate into the plasma, then glucose is not able to be adequately absorbed at the cellular level.
2. Although nutrition is established, but sugar is not adequately perceived by the body, due to a lack of glucose, the liver is connected, which additionally produces excess glucose.
3. Due to the increased activity of the liver, ketone bodies are concentrated in the plasma, which are not able to be processed in a timely manner by the body.

Then a sharp increase in plasma glucose provokes a hyperglycemic coma, and if the level of ketone bodies rises, while sugar indicators lag behind in quantity, a ketoacidotic coma develops. Depending on what kind of metabolism the patient has, and also what kind of products he uses, in addition to glucose, metabolic products that are incompletely oxidized can increase in the plasma. In this case, hypersomolar or hyperlactacidemic coma occurs. All these conditions are complications of hyperglycemic coma, which is associated with impaired metabolic processes. This condition is unsafe, with an attack, first aid is required.

Symptoms of pathology

Hyperglycemic syndrome does not appear immediately, it is not always possible to determine the onset of the pathology and distinguish clinical symptoms on your own. However, the signs gradually become more pronounced, the patient is concerned about:

• Intoxication of the body, in which a person is tormented by severe headaches, weakness, increased fatigue.
• Strong feeling of thirst and dryness of the mucous membranes of the oral cavity.
• Increased urge to urinate.
• The skin is dry, itchy.
• Severe nausea with bouts of vomiting.

Uncontrolled vomiting is one of the signs of hyperglycemic coma.

If a person has at least a couple of these symptoms, it is important to immediately measure the glucose level. If the patient has a precoma - a condition that precedes a true coma, the sugar level will exceed 33-35 mmol / l, the symptoms are disturbing:

• anuria;
• uncontrolled vomiting;
• the smell of acetone from the oral cavity;
• abdominal pain;
• stool disorder;
• confusion;
• decrease in temperature indicators.

After such signs, the patient develops a true hyperglycemic coma. The patient is completely unconscious, there is no reaction to external stimuli. If the body is young, and the provision of emergency care was modern, then the unconscious state lasts an average of up to 3 days, with a severe course and inadequate response, a person often dies within a day.

Features in children

In a child, a coma occurs already at sugar levels within 12 mmol / l. The main causes of the condition are the same as in adults - incorrect dosage, malnutrition, long breaks between meals. However, due to dietary violations, children suffer more often. The child is not yet aware of the full danger of the pathology, therefore, without the knowledge of the parents, he can eat more sweets than he should, and this already carries a danger and leads to complications.

Often, hyperglycemic coma in children develops due to a violation of the established dosage of insulin. For example, the baby fell ill with a cold, but the parent did not inform the doctor and began to treat the baby on his own. However, not all parents are aware that high doses of anti-cold and expectorant children's drugs contain sugar, and the dosage of insulin should be adjusted accordingly. All this leads to complications and consequences. An ambulance should be called without fail if the child has the following symptoms:

• violation of general well-being, in which the baby is lethargic, drowsy, refuses to eat;
• increased urge to urinate;
• indigestion, indigestion;
• shock and disorientation;
• inhibition of reflexes;
• bluish tint of the skin of the lips;
• dark coating on the tongue.

Emergency care for hyperglycemic coma

If the patient is unconscious, then first of all it is necessary to measure the pulse.

If relatives observe such signs in a patient with diabetes mellitus, one must be able to provide first aid. If the patient has not lost consciousness, he understands everything, then he will provide the necessary assistance to himself, since in the hospital diabetics are taught the basic techniques that help normalize the condition. In this case, it is important to inject the calculated dose of insulin. In an unconscious state, all the necessary manipulations are carried out by outsiders. Here it is important not to harm, and at the same time not to let the patient die, waiting for the doctors to arrive. In this state, the algorithm of actions is as follows:

1. Determine and measure the pulse.
2. Examine the oral cavity, make sure that breathing is not disturbed.
3. Lay the victim on their side to prevent vomit from entering the trachea.

Hyperglycemic coma is the most severe and life-threatening complication. It develops as a result of an increase in insulin deficiency and a significant decrease in the utilization of glucose in the blood.

In the body of a sick person, a profound metabolic disorder occurs with the formation of a large number of ketone bodies, with the development of acidosis (disturbance of the acid-base balance), with intoxication of the central nervous system.

Signs of the development of hyperglycemic coma

Hyperglycemic coma is characterized by gradual development over several hours or days. The harbingers of its formation, the so-called prodromal period, are weakness, apathy, drowsiness, and intense thirst.

Often the patient is disturbed by nausea, accompanied by vomiting. After a few hours or days, the smell of acetone appears from the mouth, shortness of breath, accompanied by very deep, frequent and noisy breathing. After this, there is a violation of consciousness up to its complete loss and the development of the actual coma.

Causes of the development of hyperglycemic coma

The reasons for the development of hyperglycemic coma include untimely diagnosed diabetes mellitus, its improper treatment, insufficient administration of insulin, below the dose prescribed by the doctor, diet violations in diabetes mellitus, infections of a different nature, mental trauma, surgical operations,. This complication practically does not occur in type 2 diabetes mellitus.

Symptoms of the development of hyperglycemic coma

The development of hyperglycemic coma is accompanied by a complete or partial impairment of consciousness, a sharp flushing (redness) of the face, dry skin and mucous membranes, a strong smell of acetone from the mouth, a decrease in turgor (tension of the skin-fat fold) of the skin and muscle tone.

The patient's tongue is dry and coated with a dark brown coating. Reflexes are often slow, the eyeballs are sunken and soft. Kussmaul's breathing is deep, noisy, not rapid. There are violations of the cardiovascular system, impaired renal function - first polyuria (an increase in the amount of urine excreted per day), then oliguria (a decrease in the amount of urine excreted) and anuria or the complete absence of urine output.

Arterial pressure is reduced, the pulse is frequent, thready, body temperature is below normal. In the urine, ketone bodies are determined, in the blood - hyperglycemia. If during this period the patient does not receive emergency qualified assistance, he may die.

The consequences of the development of hyperglycemic coma

From the first minutes of the development of a diabetic coma, there is a danger that the patient may choke on his own vomit or suffocate due to the retraction of the tongue.

At the last stage, violations of the functions of all vital organs and systems of the body are pronounced, which can lead to the death of the patient. There is a failure of all types of exchange. On the part of the central nervous system, there is a violation of the brain, expressed in loss of consciousness up to its complete oppression, most often occurs in the elderly and threatens with the possibility of paralysis, paresis, and a decrease in mental abilities. Reflexes decrease or disappear completely. The urinary system also suffers, the amount of urine excreted decreases until it is completely absent. With a predominant lesion of the cardiovascular system, arterial pressure falls, which can lead to myocardial infarction, the development of vascular thrombosis and, subsequently, to trophic ulcers and.

Emergency First Aid

Basically, patients with diabetes are informed about the possibility of developing hyperglycemic or diabetic coma. Therefore, if the patient's condition allows, it is recommended to find out from him and provide him with all possible assistance: if there is insulin, help the patient to introduce it.

If the patient is unconscious, then before the arrival of the ambulance team, it is recommended to ensure free airway patency, monitor the pulse. It is necessary to free the oral cavity from removable dentures, if any, turn the patient on his side in order to prevent him from choking on vomit in case of vomiting and to avoid falling of the tongue.

At the first signs of the development of a coma, it is necessary to immediately contact a medical institution for the relief of a crisis and its further treatment, this condition requires urgent emergency qualified assistance. But in all cases, you should immediately seek professional medical help.

Expert editor: Mochalov Pavel Alexandrovich| MD general practitioner

Education: Moscow Medical Institute. I. M. Sechenov, specialty - "Medicine" in 1991, in 1993 "Occupational diseases", in 1996 "Therapy".

Diabetes- this is an endocrine disease associated with absolute insulin deficiency (type 1 diabetes mellitus insulin-dependent) or relative (type 2 diabetes mellitus non-insulin dependent).

diabetic coma- one of the most severe complications of diabetes mellitus, resulting from absolute or relative insufficiency of insulin and metabolic disorders. There are two types of diabetic coma: hypo- and hyperglycemic.

Hypoglycemic coma

The clinical picture of hypoglycemic coma is characterized by loss of consciousness, psychomotor and motor impairment, hallucinations, clonic and tonic convulsions. The skin and mucous membranes are sharply pale, moist, there is profuse sweat, tachycardia with relatively normal blood pressure, breathing is rapid, shallow, rhythmic. The level of glucose in the blood decreases. A dangerous mistake is to evaluate hypoglycemic coma as hyperglycemic. The introduction of insulin in this case can be fatal. In clinical practice, the following rule is followed: if it is difficult to determine the type of coma, then at first it is better to regard it as hypoglycemic.

Intensive therapy: 20-80 ml of a 40% glucose solution are immediately injected intravenously. If it is possible to control the level of glucose in the blood, maintain it within 8-10 mmol / l by introducing a 10% glucose solution with insulin.

According to indications, glucagon, adrenaline, hydrocortisone, cocarboxylase, ascorbic acid are used.

hyperglycemic coma. The concentration of glucose in the blood sometimes reaches 55 mmol / l.

The clinical picture of hyperglycemic coma is characterized by a lack of consciousness, the skin and mucous membranes are dry, warm, moderately pale or hyperemic. Often there is a smell of acetone from the mouth. The eyeballs are sunken, “soft”, the pulse is quickened, blood pressure is reduced. There is bradypnea, respiratory rhythm disturbance (Kussmaul type), polyuria, agitation, convulsions, increased reflex activity.

There are three types of such a coma:

1. ketoacidotic
2. hyperosmolar non-ketoacidotic
3. lactatacidemic.

In the differential diagnosis of various types of hyperglycemic coma, along with clinical data, the results of laboratory studies are of great importance.

The concentration of glucose in the blood reaches 55 mmol / l, hyperosmolar syndrome develops. The fluid from the cells moves into the extracellular space, there are signs of cellular dehydration and neurological symptoms characteristic of it. The level of glucose in the urine can reach 250 mmol / l.

Fluid loss due to osmodiuresis ranges from 5 to 12 liters. At the same time, excess excretion of sodium, potassium, magnesium, calcium occurs, and, as a result, hypoelectrolythemia develops. The level of ketone bodies in the blood increases by 8-10 times, they are found in large quantities in the urine. A typical symptom of hyperglycemic coma is metabolic acidosis.

Dehydration and hypovolemia contribute to blood thickening, increasing its viscosity, disruption of rheological properties and microthrombosis.

Intensive therapy. Correction of hyperglycemia is carried out by the introduction of insulin. Preference is given to short-acting insulin as more "managed". The most effective is intravenous drip administration using dispensers at a rate of 6-10 units per hour under constant monitoring of blood glucose concentration. Depending on the level of hyperglycemia, the first dose may be increased to 20 IU. In the future, it is regulated in such a way that the glucose content in the blood decreases by 3-4 mmol / hour. The glucose level to which it is necessary to carry out correction should be below its renal threshold (8-10 mmol / l).

Elimination of dehydration - rehydration - replenishment of BCC, general fluid deficiency. It is carried out gradually under the control of CVP, blood pressure, bcc, osmolarity, glucose, sodium levels. The rate of fluid administration, their quantity and quality depend on the state of the cardiovascular system, kidney function. The following scheme is recommended:

• 1st hour, 1-2 liters of liquid are injected;
• 2-3rd hour - 500 ml;
• each subsequent hour - 250 ml.

The total volume in the first 24 hours is about 4-7 liters.

Correction of electrolyte deficiency requires constant laboratory control and monitoring of changes in the cardiovascular system and kidney function. Usually, a 1% solution of potassium chloride is administered in case of potassium deficiency, in case of sodium deficiency - isotonic and hypertonic solutions of sodium chloride. Losses of magnesium are restored with a 25% solution of magnesium sulfate and panangin.

Correction of metabolic acidosis should be aimed at activating buffer systems and normalizing the functions of the cardiovascular and respiratory systems, oxygenating blood, improving microcirculation and perfusion of organs and tissues.

If a patient with diabetes mellitus suddenly lost consciousness at a dentist’s appointment, then first of all, one should think about hypoglycemia, carry out the above measures and, in any case, call an ambulance.

Treatment of severe shock and coma should be directed to the main links of the pathophysiological reactions of the body, taking into account the causes of their occurrence.

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Symptoms of hyperglycemia and hypoglycemia

Symptoms of hyperglycemia in the acute or chronic form of the course, are in the following manifestations:

• thirst, especially excessive;
• frequent urination;
• fatigue;
• weight loss;
• blurred vision;
• skin itching, dry skin;
• dryness in the mouth;
• arrhythmia;
• Kussmaul breathing;
• sluggish infections (otitis externa, vaginal candidiasis) that are poorly cured with the use of traditional therapy;
• coma.

Acute hyperglycemia can additionally manifest itself in the following conditions:

• disturbance of consciousness;
• ketoacidosis;
• dehydration against the background of osmotic diuresis and glucosuria.

Symptoms of hypoglycemia are divided into autonomic (adrenergic, parasympathetic) and neuroglycopenic. Symptoms of the vegetative form are characterized by the following manifestations:

• increased arousal and aggressiveness, fear, anxiety, feeling of anxiety;
• excessive sweating;
• muscle tremor (trembling), muscle hypertonicity;
• increased blood pressure;
• pupil dilation;
• pale skin;
• arrhythmias;
• nausea, possibly vomiting;
• weakness;
• hunger.

Neuroglycopenic symptoms manifest themselves in the form of the following conditions:

• reduced quality of concentration;
• dizziness, headache;
• disorientation;
• violations in the coordination of movements;
• paresthesia;
• "double vision" in the eyes;
• inappropriate behavior;
• amnesia;
• circulatory and respiratory disorders;
• drowsiness;
• disturbances in consciousness;
• pre-fainting state, fainting;
• coma.

Causes of hypoglycemic coma

• long-term use of certain medications;
• overdose of insulin preparations;
• diet violation, alcohol intake;
• psycho-emotional stress, neurosis, low mood, depression and stress;
• tumor in the pancreas, excess insulin production;
• liver failure;
• overstrain of a physical scale (during heavy physical labor, during sports).

Complications of hypoglycemic coma

First aid for hypoglycemic coma is extremely important for the patient, and in particular, it is important how quickly those people who are in close proximity to him when this condition occurs will respond. The importance of providing such assistance lies in the fact that its absence can lead to cerebral edema, and this, in turn, will provoke the occurrence of irreversible damage to the central nervous system.

It should be noted that with frequent attacks of hypoglycemia, as well as with a frequent state of hypoglycemic coma, adult patients experience personality changes, while children have a decrease in intelligence. In both cases, the possibility of a lethal outcome is not excluded.

As for the state of hypoglycemic coma in the elderly, and especially in those for whom ischemic heart / brain disease and cardiovascular diseases are relevant, it is especially dangerous, because myocardial infarction or stroke can act as a complication of its course. .

Given this feature, it is imperative to undergo an ECG after the symptoms of hypoglycemia are stopped. With prolonged episodes of hypoglycemic coma, accompanied by the severity of its characteristic manifestations, encephalopathy may occur, that is, diffuse brain damage in combination with oxygen starvation and impaired blood supply to the brain tissue. In this case, the death of nerve cells occurs, degradation of the personality is noted.

First aid for hypoglycemic coma: precautions

For the correct first aid in a condition caused by a hypoglycemic coma, it is important to clearly determine which of the symptoms of this condition indicate hyperglycemia (in which the blood glucose level rises), and which ones indicate hypoglycemia (in which, accordingly, the glucose level is lowered). The fact is that both of these cases require the implementation of measures that are opposite to each other.

We remind our readers that a high level of sugar is accompanied by an increase in thirst, weakness and nausea. Unconsciousness is accompanied by dry skin and a general decrease in the tone of the eyeballs. In addition, the patient has noisy pronounced breathing with a characteristic "apple" smell and acetone. If for the patient it is important to lower the level of sugar, then there is a pronounced weakness and trembling in the body, profuse sweating. Unconsciousness may be accompanied by convulsions and lack of corneal response to touch.

To bring out a person who is in a state of diabetic coma (hyperglycemic coma), an injection of insulin is urgently needed. As a rule, patients with diabetes have a first-aid kit with them in case of such a condition, in which there is everything that is needed for this injection (dosage instructions, cotton wool, alcohol, syringes and, in fact, insulin).

Considering the fact that diabetic patients, who, in fact, are faced with the condition in question, have reduced immunity, it is important to exclude in every possible way the possibility of infection of the injection sites, and also strictly observe the measures of insulin asepsis, as usual they receive.

That is why, in order to provide first aid for hyperglycemic coma on the street in accordance with this requirement, it is necessary, first of all, to search the patient for the presence of a first aid kit with insulin. If available, a dose of insulin (50-100 units) is administered into the thigh or upper arm. Considering that the patient may certainly have injection marks, it should not be difficult to navigate this.

An ambulance is called without fail, because, simultaneously with insulin, the patient will need to administer a glucose solution (40%) and a saline solution with a glucose solution (up to 4000 ml, 5%). Further, over the next few hours from the moment of insulin administration, the amount of fats and proteins consumed is reduced, meals should contain about 300 grams (minimum) of easily digestible carbohydrates (jelly, fruits and juices), alkaline mineral waters are recommended for consumption.

Hypoglycemic coma: first aid

As for hypoglycemia, there are certain measures here that also require implementation in order to alleviate the condition as soon as possible:

• The patient is urgently given something sweet. It can be honey, ice cream, candy, jam, sugar cubes, sweetened water, juice, lemonade or sweet tea;
• Comfortable lying or sitting position is provided;
• In case of loss of consciousness, the patient is laid on his side, sugar is placed on his cheek;
• As already noted, a mandatory measure in providing assistance with hypoglycemic coma is to call an ambulance team.

When the patient is conscious, which will allow him to swallow the liquid on his own, a sugar solution is given for use. To do this, dilute 1-2 tablespoons of it in half a glass of water.

The lack of consciousness in a patient requires intravenous administration of a glucose solution (40%). It is also possible to increase blood sugar levels by administering a subcutaneous injection of adrenaline solution (0.1%, 1 ml).

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coma

Diabetes is an endocrine disease associated with absolute insulin deficiency (type 1 diabetes mellitus, insulin-dependent) or relative(diabetes mellitus type 2 non-insulin dependent).

diabetic coma- one of the most severe complications of diabetes mellitus, resulting from absolute or relative insufficiency of insulin and metabolic disorders. There are two types of diabetic coma: hypo- and hyperglycemic.

Hypoglycemic coma develops with a sharp decrease in blood glucose levels to 2-1 mmol / l. It occurs when there is a violation of the diet, with an overdose of insulin, the presence of a hormonal tumor (insulinoma).

Clinical picture hypoglycemic coma is characterized by loss of consciousness, psychomotor and motor disturbance, hallucinations, clonic and tonic convulsions. The skin and mucous membranes are sharply pale, moist, there is profuse sweat, tachycardia with relatively normal blood pressure, breathing is rapid, shallow, rhythmic. Blood glucose level drops

Intensive therapy : immediately in / in injected 20-80 ml of 40% glucose solution. If it is possible to control the level of glucose in the blood, maintain it within 8-10 mmol / l by introducing a 10% glucose solution with insulin.

According to indications, glucagon, adrenaline, hydrocortisone, cocarboxylase, ascorbic acid are used.

For the prevention and treatment of cerebral edema, mechanical ventilation is performed in the hyperventilation mode, intravenous infusions of 20% mannitol.

Ghyperglycemic coma. The concentration of glucose in the blood sometimes reaches

55 mmol/l.

Clinical picture hyperglycemic coma is characterized by a lack of consciousness, the skin and mucous membranes are dry, warm, moderately pale or hyperemic. Often felt smell of acetone from mouth. The eyeballs are sunken, “soft”, the pulse is quickened, blood pressure is reduced. There is bradypnea, respiratory rhythm disturbance (Kussmaul type), polyuria, agitation, convulsions, increased reflex activity.

Intensive therapy. Correction of hyperglycemia is carried out by the introduction of insulin. Preference is given to short-acting insulin as more "managed". The most effective is intravenous drip administration using dispensers at a rate of 6-10 units per hour under constant monitoring of blood glucose concentration. Depending on the level of hyperglycemia, the first dose may be increased to 20 IU. Correction of metabolic acidosis should be aimed at activating buffer systems and normalizing the functions of the cardiovascular and respiratory systems, oxygenating blood, improving microcirculation and perfusion of organs and tissues.

What is hyperglycemic (diabetic) coma

- a relatively slowly developing condition associated with an increase in blood glucose levels in diabetes mellitus and the accumulation of toxic conversion products

What provokes hyperglycemic (diabetic) coma:

Uncontrolled treatment of diabetes mellitus with inadequate insulin administration.

Stop using insulin.

At the beginning of diabetes mellitus, when the patient is not yet aware of his disease at all, before the diagnosis is made, as a rule, diabetic (hyperglycemic) coma begins to develop.

Various dietary errors, injuries and infectious diseases can provoke the development of diabetic (hyperglycemic) coma in patients with diabetes mellitus.

It occurs when diabetes mellitus proceeds for a long time with little symptoms and the patient does not receive insulin or receives small doses.

Symptoms of hyperglycemic (diabetic) coma:

Precomatous and comatose state of patients with diabetes mellitus requires their urgent hospitalization. The complex treatment of coma includes the restoration of insulin deficiency, the fight against dehydration, acidosis, loss of electrolytes. In the initial stage of a diabetic coma, insulin must first be administered. Only crystalline (simple) insulin is administered and in no case are long-acting drugs. Dosage of insulin calculated depending on the depth of the coma. With a mild degree of coma, 100 IU are administered, with severe coma - 120-160 IU and with a deep one - 200 IU of insulin. Due to impaired peripheral circulation during the development of cardiovascular insufficiency during the period of diabetic coma, the absorption of injected drugs from the subcutaneous tissue slows down, therefore, half of the first dose of insulin should be administered intravenously by bolus in 20 ml of isotonic sodium chloride solution.

For elderly patients, it is advisable to administer no more than 50-100 IU of insulin because of the threat of developing coronary insufficiency in them. Half the full dose of insulin is administered in the precoma.

In the future, insulin is administered every 2 hours. The dose is selected depending on the level of blood glucose. If after 2 hours the blood glucose has increased, then the dose of insulin administered is doubled. The total amount of insulin administered in diabetic coma ranges from 400 to 1000 IU per day. Along with insulin, glucose should be administered, which has an antiketogenic effect. It is recommended to start the introduction of glucose after its level in the blood under the influence of insulin begins to fall. Enter 5% glucose solution intravenously. To restore the lost fluid and electrolytes, 1-2 liters per hour of an isotonic sodium chloride solution are injected intravenously in combination with 15-20 ml of a 10% potassium chloride solution heated to body temperature. In total enter 5 6 l of liquid a day; patients over 60 years of age, as well as in the presence of cardiovascular insufficiency - no more than 2-3 liters. To combat metabolic acidosis, 200-400 ml of a 4-8% solution of freshly prepared sodium bicarbonate is injected intravenously, which must not be mixed with other solutions. Intravenous administration of 100-200 mg of cocarboxylase, 3-5 ml of a 5% solution of ascorbic acid is shown. To restore hemodynamic disorders, cardiac glycosides are prescribed (1 ml of a 0.06% solution of corglycon intravenously), 1-2 ml of a 20% solution of caffeine or 2 ml of cordiamine are injected subcutaneously or intravenously.

Hyperglycemic hyperketonemic coma

A terrible complication of diabetes mellitus, which is the result of a pronounced insulin deficiency and a decrease in glucose utilization by tissues, which leads to severe ketoacidosis, disruption of all types of metabolism, dysfunction of all organs and systems, primarily the nervous system, and loss of consciousness.

Algorithm for emergency care :

Urgently call a doctor to provide qualified medical care;

Provide monitoring of the patient's condition (BP, pulse, respiratory rate);

Take blood and urine from the patient for research;

Prepare emergency medicines for the arrival of the doctor:

for intravenous drip - Ringer's solution, 4% sodium bicarbonate solution, 5% glucose solution, 0.9% sodium chloride solution;

short-acting insulin preparations (homorap, actrapid, insulrap, humalog);

cardiac glycosides: 0.05% strophanthin solution or 0.06% corglicon solution, 10% caffeine solution, 1% mezaton solution;

cocarboxylase, ascorbic acid;

warm 2% solution of soda for enema;

5. Ensure the administration of medicines prescribed by the doctor

Hypoglycemic coma.

It occurs as a result of a sharp decrease in blood sugar levels (hypoglycemia), most often in diabetic patients receiving insulin. The basis of the pathogenesis of hypoglycemia is the inconsistency of insulinemia with the level of glycemia. In typical cases, hypoglycemia occurs due to an overdose of insulin, significant physical activity or insufficient food intake after its administration and develops 1 to 2 hours after insulin injection (sometimes later). With the introduction of long-acting insulin preparations, a hypoglycemic state and coma may develop after 4-5 hours, but also with insufficient food intake that does not correspond to the administered dose of the drug.

Algorithm for emergency care:

Enter intravenously 10-20 ml. 40% glucose solution;

With a decrease in blood pressure, introduce intravenous plasma and its substitutes: polyglucin, rheopolyglucin, albumin and cardiac glycosides: corglicon - 0.06% solution 0.5 mg / kg intravenously slowly, hormones, prednisolone, hydrocortisone 5 ml / kg;

At convulsions introduce diazepam 0.3-0.5 ml/kg intravenously slowly or sodium oxybutyrate 20% solution 0.5-0.75 ml/kg.

The main signs of diabetic and hypoglycemic coma

Diabetic precoma and coma	Hypoglycemic precoma and coma
Causes: the patient did not receive or receive little insulin.	Causes: the patient received a lot of insulin or after it did not accept introduction enough carbohydrates
Symptoms: lethargy, drowsiness, weakness, gradual deterioration state to coma.	Symptoms: anxiety, excitement, delirium, change psyche, often sudden obscuration or loss consciousness.
The smell of acetone from the mouth	No acetone smell
Lack of appetite nausea vomiting.	Increased appetite, feeling of hunger
Deep noisy breathing	normal breathing
Dry skin	Wet skin, often profuse sweat.
Frequent poor filling pulse	Sometimes slow, often intermittent pulse.
Mostly normal temperature	The temperature is often below normal.
Weakness of the muscles.	trembling limbs, cramps, muscle density
Abdominal pain is common	No abdominal pain
Urine contains sugar and acetone.	There is no sugar in the urine, sometimes there may be traces of acetone.
Blood sugar is very high	Blood sugar is below normal

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Hyperglycemic (diabetic) coma

1. Insufficient dose of insulin and high blood sugar

It begins gradually with general malaise, weakness, headache, loss of appetite, depression.

Then there are pains in the epigastric region, noisy breathing - Kussmaul breathing, with the smell of acetone. Drowsiness and apathy progresses, up to a complete loss of consciousness.

The skin is dry, cold, the face is hyperimposed, haggard,

Tongue dry, coated. The eyeballs are soft, the pulse is quickened,

Weak, blood pressure is reduced. Muscles are relaxed, tendon reflexes are reduced or absent. Auscultatory: pleural friction rub, temperature is normal.

Laboratory:

1. Hyperglycemia

2. Hyperkitonemia

4. In urine: high glucosuria, sharply positive reaction to acetone.

1. Introduction of a simple short-acting insulin.

2. The introduction of a large amount of liquid.

1. Insulin overdose

2. If a person has not eaten after taking insulin.

Develops quickly, suddenly.

There is a feeling of hunger, severe weakness, trembling of the limbs. In severe cases, there may be seizures.

Examination: the skin is moist, breathing is not disturbed (superficial), blood pressure is increased.

Blood sugar is reduced.

1. iv 40% glucose 20-40 ml.

Completed by: Sukhov Anton Anatolyevich, Kaluga, 2002.

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Diabetes mellitus- a disease caused by absolute or relative insufficiency of insulin, accompanied by a metabolic disorder of proteins, fats, carbohydrates and a gradual defeat of all organs and systems. In a healthy person, normal fasting blood glucose levels range from 3.3 to 5.5. mmol/l, and 2 hours after a meal does not exceed 7.8 mmol/l. The rise in blood glucose is due to the lack or lack of insulin in the body. In accordance with the international classification, it is customary to distinguish two main types of diabetes:

Type 1 diabetes mellitus (insulin-dependent diabetes): This type of diabetes is characterized by the development of the disease in childhood, adolescence and young age. Many of the patients are males. Insulin is not produced by the pancreas or is produced in insufficient quantities. The patient from the very beginning of the disease needs injections of insulin preparations.

Type 2 diabetes mellitus (non-insulin-dependent diabetes): It occurs predominantly in people over 45 years of age. The body is not able to effectively use the insulin produced in the pancreas - there is tissue resistance to the action of insulin along with its increased production.

There is also a special type of diabetes that develops in some cases during pregnancy called gestational diabetes. Although this type of diabetes may disappear completely after childbirth, during pregnancy this disease causes significant harm to the health of mother and child.

Reasons for development: In the development of type 1 diabetes mellitus, the main role is played by the presence of a genetic predisposition, the implementation of which is facilitated by seasonal viral infections (ARVI, influenza), mumps, rubella, and infectious hepatitis.

For the development of type 2 diabetes, the genetic factor plays a lesser role. Of great importance are overweight and obesity, low physical activity, a diet high in fat and low in dietary fiber, age, low birth weight. Risk factors for developing diabetes are also stressful situations, the presence of chronic gastritis and cholecystitis, coronary heart disease.

Signs of the disease: Characteristic early signs of type 1 diabetes are severe thirst, constant hunger, frequent urination, weight loss in a short time, progressive fatigue, poor school performance, blurred vision.

Patients with type 2 diabetes rarely experience these symptoms. The onset of the disease is in most cases latent, thirst is moderate or absent. Overweight is characteristic, slight weight loss at the onset of the disease is possible. In many cases, type 2 diabetes is asymptomatic and the diagnosis is not made until several years after the onset of the disease, when late complications are already present. Nearly 50% of people with type 2 diabetes do not know they have it.

Diabetes causes damage to various organs and tissues, there is a change in the skin of the subcutaneous tissue, dryness, peeling, cracks are observed, the musculoskeletal system, respiratory organs, cardiovascular, nervous, and digestive systems can be affected. Late complications of diabetes are hyper- and hypoglycemic coma.

Hyperglycemia (diabetic coma) develops with a high content of glucose in the blood - more than 18.2 - 20 mmol / l. Causes: violation of the regimen of insulin therapy, diet, stress, infectious diseases.

Signs of hyperglycemia: frequent urination, loss of appetite, severe constant thirst and dry mouth, especially at night, dry skin, severe weakness, nausea, vomiting, frequent stools, the smell of acetone from the mouth appears. The child appears inattention in the classroom, apathy, drowsiness.

First aid: the patient must be given a glass of warm water without sugar, call his parents and tell them his suspicions, call an ambulance. Treatment of this complication is carried out exclusively in the hospital.

Hypoglycemic coma - a state of the body caused by a sharp decrease in blood sugar levels and insufficient supply of glucose to the cells of the central nervous system.

Signs of hypoglycemia: severe sweating (wet skin) and pallor, hunger, agitation, irritability, palpitations, headache, trembling of the body, hands, handwriting changes, balance is disturbed, stammering appears, thinking (memory) worsens - it is difficult for a child to remember how to write something or another word, he can't cope with a simple task. Vision may be impaired, sensitivity may be impaired.

First aid: give the child easily digestible carbohydrates - sweet drink, tea with honey, glucose tablets, sweets, a piece of sugar. It is not recommended to give chocolate, ice cream and some other sweets, as the fats contained in them slow down the absorption of carbohydrates. If you lose consciousness, you should immediately call an ambulance. Medical care begins with intravenous administration of glucose.

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Etiology[edit | edit wiki text]

Hypoglycemic coma develops in patients with diabetes mellitus, in most cases, when the dose of administered insulin or sulfonylurea drugs and incoming food, especially carbohydrate, do not match. In diabetes mellitus, hypoglycemic coma develops much more often than ketoacidotic coma.

Typically, hypoglycemia and hypoglycemic coma occur in patients with severe, extremely labile forms of insulin-dependent diabetes mellitus, in which it is impossible to establish an external cause for a sudden increase in insulin sensitivity. In other cases, provoking moments are long breaks between meals, increased physical activity, vomiting, diarrhea and other pathological conditions. Accompanying diabetes mellitus disorders of the liver, intestines, endocrine status, the development of renal failure may lead to severe hypoglycemia. More often, hypoglycemic coma develops with excessive administration of insulin, which can occur in the following cases:

• dosage error (concentration of the insulin preparation, for example, with U40 syringes instead of U100, that is, 2.5 times more than the prescribed one, or an incorrectly dialed dose of insulin in the syringe),
• an error in the administration of the drug (not under the skin, but intramuscularly) - a long needle, or deliberate intramuscular administration in order to accelerate and enhance the effect of the hormone,
• not taking carbohydrates after a dose of short-acting insulin (“forgot to eat” - second breakfast, afternoon snack or second dinner at the peak of the short-acting insulin drug),
• “unscheduled” physical activity in the absence of additional carbohydrate intake: injected insulin → “forgot” to eat (did not eat additional carbohydrates to ensure unusual physical activity) → rode a bike [skiing, playing football, swimming pool, skating rink, etc.] → hypoglycemia → coma,
• massaging the insulin injection site (deliberately - in order to accelerate the action of a short-acting insulin preparation or accidentally - while cycling, an injection of insulin made into the thigh),
• release of a large amount of active hormone upon rupture of the insulin-antibody complex,
• against the background of alcohol intake,
• in the presence of fatty degeneration of the liver,
• on the background of chronic renal failure,
• in early pregnancy,
• suicidal actions
• insulin shocks in psychiatric practice and so on.

In persons with diabetes, hypoglycemic coma may be the result of an overdose of insulin, in particular when removing the patient from a state of ketoacidosis.

The development of a severe hypoglycemic reaction is possible against the background of alcohol intake, the hypoglycemic effect of which is practically ignored, taking into account only carbohydrates in the composition of alcoholic beverages when making a diet). Alcohol inhibits the synthesis of glucose from non-carbohydrate raw materials in the liver, thereby increasing the incidence of hypoglycemia in patients on insulin therapy. The more alcohol is drunk, the longer the inhibition of gluconeogenesis, so hypoglycemia can occur even several hours after drinking alcohol.

A low concentration of glucose in the blood is recorded if:

• glucose is removed from the blood at a faster rate than it is absorbed in the intestine or synthesized by the liver,
• the breakdown of glycogen and / or the synthesis of glucose from non-carbohydrate raw materials in the liver cannot compensate for the rate of glucose elimination,
• combination of the above factors.

Often, the onset of compensation for diabetes mellitus increases the sensitivity of peripheral tissues to insulin, which requires a timely reduction in the dose of an externally administered hormone.

Sulfanilamide drugs can rarely cause hypoglycemic reactions, they can mainly occur in elderly patients with a combination of diabetes mellitus with kidney, liver or heart failure, as well as with starvation or malnutrition. The use of certain drugs in combination with sulfonamides can provoke the development of a coma. For example, acetylsalicylic acid and other salicylates, by reducing the binding of sulfonamides to plasma proteins and lowering their excretion in the urine, create conditions for the development of a hypoglycemic reaction.

Pathogenesis[edit | edit wiki text]

Glucose is the main energy source of the brain. The nervous system consumes about 20% of the glucose circulating in the blood. The particular sensitivity of the central nervous system (CNS) to hypoglycemia is explained by the fact that, unlike other tissues of the body, the brain does not have reserves of carbohydrates and is not able to use circulating free fatty acids as an energy source. When the supply of glucose is stopped for 5-7 minutes, irreversible changes occur in the cells of the cerebral cortex of the cerebral hemispheres, while the most differentiated elements of the cortex die. With hypoglycemia, the uptake of glucose by cells, and first of all, by brain cells, drops sharply.

Under physiological conditions, the catabolic pathways of carbohydrate, protein and fat metabolism at a certain stage intersect in the Krebs cycle - a universal source of energy supply for the body. In conditions of carbohydrate deficiency in cells, there is no substrate for the Krebs cycle, and as a result of the breakdown of free fatty acids, the level of acetyl-CoA rises - its amount exceeds the physiological norm, use in the Krebs cycle is limited due to oxaloacetate deficiency caused by a lack of carbohydrates, and the only acetyl-CoA utilization pathway - ketone bodies are synthesized.

The manifestation of hypoglycemia is the result of the reaction of the central nervous system to a decrease in blood glucose levels and inhibition of brain metabolism. The “youngest” in the phylogenetic aspect of the cerebral cortex is the first to react to a lack of glucose in the circulating blood plasma (a hypoglycemic aura or precursors of a hypoglycemic coma develops), then the cerebellum (coordination of movements). If the level of glucose in the blood is not increased at this moment, then these sections are followed by a reaction of subcortical-diencephalic structures, and only in the terminal stage of hypoglycemia the process captures the medulla oblongata with its vital centers - coma develops. Thus, hypoglycemic coma is a kind of crown of neglected hypoglycemia.

With a decrease in glucose levels, mechanisms are activated that are aimed at glycogenolysis, gluconeogenesis, the mobilization of free fatty acids, and ketogenesis. These mechanisms involve mainly 4 hormones: norepinephrine, glucagon, cortisol and growth hormone. Clinical manifestations are due to hyperadrenalemia and increased activity of the sympathetic nervous system. If the reaction to hypoglycemia, expressed in the release of norepinephrine, occurs quickly, then the patient develops weakness, tremor, tachycardia, sweating, anxiety and hunger; symptoms from the central nervous system include dizziness, headache, diplopia, blurred vision, behavioral disturbances, confusion, incoherent speech, loss of consciousness, convulsions. With the slow development of hypoglycemia, changes associated with the central nervous system prevail - the reaction to norepinephrine may be absent. Hypoglycemia indicates a violation of the homeostatic regulation of the concentration of glucose in the blood; the listed symptoms are just an excuse to search for the cause of the violation.

Hypoglycemia is a condition that develops in patients with diabetes mellitus when the level of glycemia falls below 50 mg% (2.78 mmol / l) or when it decreases very quickly with normal or even elevated levels. Clinical observations indicate that such relative hypoglycemia is possible when patients with a high level of glycemia are in good health. Reducing its level to normal leads to a worsening of the condition: headache, dizziness, weakness. In the case of diabetes, hypoglycemic coma can develop with a sharp decrease in glycemia (plasma glucose) by more than 5 mmol / l (regardless of the initial level). The central nervous system does not react to the absolute value of glycemia, but to its sharp changes (it does not have time to adapt to the extraction of glucose from a less concentrated solution). It is this mechanism that leads to the definition of "normal" or even elevated levels of glycemia in the development of hypoglycemic coma in patients treated with insulin and have not achieved satisfactory compensation of carbohydrate metabolism.

Clinical picture[edit | edit wiki text]

As a rule, it develops suddenly. With mild initial hypoglycemia, the patient develops a feeling of heat, trembling of the hands and the whole body, sometimes headache, hunger, excessive sweating, palpitations, general weakness. The initial symptoms of hypoglycemia are usually easily eliminated by the timely intake of carbohydrates - all persons receiving insulin therapy should carry glucose tablets (sugar cubes, sweets, juice) with them in case of hypoglycemia and use them in a timely manner.

When treated with long-acting insulin preparations (peak action - evening and night hours), hypoglycemic reactions are possible in the afternoon and at night. If severe hypoglycemia develops at night, during sleep, they may go unnoticed for a long time. Sleep becomes superficial, disturbing, nightmares are frequent. In a dream, children cry, scream, and upon awakening, confusion and retrograde amnesia are noted. After such nights, patients remain listless, capricious, irritable, sullen and apathetic throughout the day. In the morning, patients complain of weakness, some of nightmares. Fasting glucose in the morning can be high ('reactive' glycemia to a nighttime drop in blood sugar).

A patient in a hypoglycemic coma is pale, the skin is moist, tachycardia is noted, breathing is even, the turgor of the eyeballs is normal, the tongue is moist, there is no smell of acetone, muscle tone is increased. If help is not provided, as the hypoglycemic coma deepens, breathing becomes shallow, blood pressure decreases, bradycardia, hypothermia are noted, muscle atony, hypo- and areflexia develop. Pupillary response to light and corneal reflexes are absent.

If the initial period of hypoglycemia remains unrecognized, the patient's condition deteriorates sharply - convulsions of various muscle groups, trismus, general arousal, vomiting, and depression of consciousness develop into a hypoglycemic coma. Glucose in the urine is usually not determined, the reaction of urine to acetone may be positive or negative, depending on the previous degree of compensation for carbohydrate metabolism.

Hypoglycemia can also develop against the background of a decompensated course of labile diabetes mellitus with ketoacidosis. In response to hypoglycemia, the secretion of contrainsular hormones increases compensatory, which contributes to the occurrence of ketoacidosis, decompensation of diabetes mellitus, impaired vascular tone (pressor effect of catecholamines), and the development of thromboembolic complications.

In long-term ill individuals with chronic hyperglycemia, symptoms of hypoglycemia can be observed at normal levels of glycemia, in the absence of an absolute decrease in glucose levels (at 3.3 ... 6.6 mmol / l, and sometimes even higher). Such conditions often occur with significant, rapidly occurring changes in glycemic levels (for example, a rapid decrease from 18 ... 19 mmol / l to 7 ... 8 mmol / l).

In the development of a hypoglycemic reaction, 5 stages are distinguished
I stage - cortical,	characterized by the appearance of hunger, irritability, headache, mood changes. At this stage, the behavior of patients is adequate, but not everyone feels the onset of hypoglycemia. An objective examination shows tachycardia, moisture of the skin.
II stage - subcortical-diencephalic,	manifested by vegetative reactions and inadequate behavior. The clinical picture is characterized by profuse sweating, increased salivation, tremor, diplopia, mannerisms (aggressiveness or fun, attempts to get food).
III stage - hypoglycemia,	due to the involvement of the midbrain in the pathological process and is characterized by a sharp increase in muscle tone, the development of tonic-clonic convulsions resembling an epileptic seizure. An objective examination determines the symptom of Babinsky, dilated pupils, the moisture of the skin, tachycardia, and arterial hypertension remain.
IV stage - actually coma,	due to involvement in the pathological process of the upper sections of the medulla oblongata. The clinical picture is accompanied by a complete loss of consciousness. An objective examination shows an increase in tendon and periosteal reflexes, the tone of the eyeballs is normal or increased, the pupils are dilated. The skin is moist, breathing is normal, heart sounds are increased, the pulse is quickened, blood pressure is normal or slightly increased.
Stage V - deep coma,	due to involvement in the pathological process of the lower sections of the medulla oblongata and increasing hyperhidrosis. Progression of a coma is clinically noted: areflexia is observed, muscle tone decreases, sweating stops, heart rhythm is disturbed, blood pressure decreases, respiratory failure of central genesis is possible.

A dangerous complication is cerebral edema, which is manifested by meningeal symptoms, vomiting, hyperthermia, respiratory failure and cardiac activity.

Diagnostics[edit | edit wiki text]

The main biochemical criterion for diagnosing hypoglycemia is low blood glucose:

• the first symptoms of hypoglycemia appear when it drops to 3.33-2.77 mmol / l (60-50 mg%);
• at a glycemic level of 2.77-1.66 mmol / l (50-30 mg%), all typical signs of hypoglycemia are noted;
• loss of consciousness usually occurs at a blood glucose level of 1.38-1.65 mmol / l (25-30 mg%) and below.

The rate at which glycemia decreases is essential. In patients with long-term uncompensated insulin-dependent diabetes mellitus, hypoglycemic coma may develop with normal or even elevated glycemia (11.1 mmol / l, 200 mg% and below). This occurs when glycemia falls rapidly from very high levels to lower levels (for example, from 22.2 mmol/L, 400 mg% to 11.1 mmol/L, 200 mg%, etc.). Other laboratory findings in hypoglycemic coma are nonspecific. Glucose in the urine is usually absent, but in diabetic patients it can be determined if it is excreted in the urine before the development of coma.

The clinical picture in combination with low glycemia makes it possible to establish the diagnosis: hypoglycemic coma.

Differential diagnosis[edit | edit wiki text]

It is necessary to distinguish hypoglycemia(which occurs in a healthy individual during fasting) and hypoglycemic coma- extreme degree of hypoglycemia with depression of consciousness caused by an overdose of insulin.

It is incorrect to classify hypoglycemic coma (acute excess insulin) as "diabetic" coma, associated with an absolute or relative lack of insulin. So, insulin shock (a variant of hypoglycemic coma) does not occur in patients with diabetes mellitus and, accordingly, is not a "diabetic coma" ...

There are three types of diabetic coma:

• ketoacidosis,
• lactic acidosis,
• hyperosmolar diabetic coma.

Two types of diabetic coma (ketoacidosis and hyperosmolar diabetic coma) represent the extreme metabolic disorders characteristic of diabetes mellitus. Lactic acidosis is not a specific syndrome for diabetes mellitus (it usually develops as a complication of severe general diseases against its background).

Most often, hypoglycemic coma should be distinguished from diabetic ketoacidotic coma. Let's quote the table

Differential diagnosis of diabetic and hypoglycemic coma
Indicators	Diabetic coma (ketoacidosis)	Hypoglycemic coma
	Causes
Dose of insulin	Insufficient	Excess
Nutrition	Violation of the diet (abuse of fats)	Insufficient (after administration of insulin)
Other	Intercurrent disease	Labile course of diabetes - vomiting, diarrhea, improvement (compensation)
	Dynamics
Development	prodromal	Fast and sudden
Fading consciousness	gradual	Fast and complete
	signs
Symptoms	Dry skin, dehydration, cyanosis of the skin and mucous membranes	Paleness and sweating
Language	Dry	Wet
muscles	Hypotension	Rigidity, trismus of masticatory muscles
convulsions	Not	Yes, Babinski's symptom
Tone of the eyeballs	Downgraded	Normal
Breath	Kussmaul (large, noisy)	Normal
Pulse	Frequent, poor filling	Tachycardia, sometimes bradycardia
Appetite	Lack of appetite, nausea, vomiting	Early development of hypoglycemia
Abdominal syndrome	Sometimes	Can not be
Body temperature	Below normal	More often normal
peripheral blood	Often hematorenal syndrome	Normal
The smell of acetone in the exhaled air	There is	Usually no
Acetonuria and glycosuria	There is	Not
hyperglycemia	There is	Blood glucose is low or normal (but may be high)
Reserve alkalinity of blood	The fall	Normal
Hyperketonemia	There is	Not

Some ambiguity of the parameters in the column "Hypoglycemic coma" is explained by the fact that this type of acute decompensation of diabetes mellitus can develop against the background of previously disturbed indicators of carbohydrate metabolism. For example, with ketoacidosis, the patient unnecessarily increased the dose or missed a meal - both glucose and acetone left over from the previous state will be determined in the urine. In this situation, it is possible to determine an increased level of glycemia, since the nervous system reacts not only to an absolutely low blood glucose index, but also to its sharp decrease (more than 5 mmol / l). In addition, the option of "hungry acetone" is possible, that is, the presence of ketone bodies in the urine in the complete absence of glucose - for more details, see Syndrome of Chronic Insulin Overdose. (In response to hypoglycemia, the secretion of contra-insulin hormones increases compensatory, which contributes to the occurrence of ketoacidosis and decompensation of diabetes mellitus).

Treatment[edit | edit wiki text]

It was noted above that hypoglycemic coma develops suddenly, therefore, as with any coma, treatment should be urgent. The main therapeutic measures are carried out at the prehospital stage, and only if they are unsuccessful, therapy is continued after hospitalization.

• They begin to inject glucose into the body of the victim. More often this is done by relatives or friends familiar with the nature of the disease; police officers who found a "DIABETES" card in the victim's pocket or psychiatric teams who are unnecessarily called in in such situations.

If possible, a 40% glucose solution (20-100 ml) is injected into the vein until the patient comes out of the coma. In severe cases, epinephrine (1 ml of a 0.1% solution under the skin) or glucocorticoids intravenously or intramuscularly or glucagon are used according to the attached instructions.

If it is not possible to inject, instruct someone to call an ambulance and proceed with the administration of glucose in all available ways:

1. while the swallowing reflex is preserved - the victim is given to drink a glucose solution or any sweet juice (grape, apple and the like, preference is given to juices without pulp, sweetener drinks are useless here),
2. if there is no swallowing reflex, and the pupils are wide and do not react to light, a glucose solution is dripped under the victim's tongue, because even in a coma with a microcirculatory disorder, the ability to absorb glucose from under the tongue is preserved, but do it with caution - they drip in small amounts so that the victim did not choke (in a deep coma, a person loses the swallowing reflex). Manufacturers produce glucose in the form of a gel - with sufficient experience, you can use a gel or honey, the chemical formula of which is identical to sucrose.

Before establishing the nature of the coma, determining the level of glucose in the blood, the administration of insulin is impractical and even dangerously. So, with hypoglycemic coma, insulin aggravates the severity of disorders, its administration can be fatal. In no case do they inject insulin (usually a syringe is found in the pocket of the victim), since glucose will save a life or not harm (in a diabetic coma, the amount of glucose that the victim will consume will not significantly change the situation - too much dilution - in an adult it is 5 liters circulating blood and additional milliliters of miserly introduced), but the introduced hormone insulin in case of hypoglycemic coma sharply reduces the body's chances to cope with the situation on its own. By the way, some manufacturers equip their means of administering insulin with an automatic lock. This is done to exclude the possibility of "unconscious" administration of insulin.

Indications for emergency hospitalization[edit | edit wiki text]

• with repeated intravenous administration of glucose, hypoglycemia is not stopped and the consciousness of the victim is not restored;
• the hypoglycemic state was stopped at the prehospital stage, however, symptoms of cardiovascular, cerebral disorders, neurological disorders persist or appear, which are not characteristic of the patient's usual condition;
• the development of repeated hypoglycemic reactions soon after the therapeutic measures.

Prevention[edit | edit wiki text]

Prevention of hypoglycemia consists in strict adherence to the regime of work and diet, adequate and timely correction of the dose of insulin, if necessary.

The main efforts should be directed to the prevention of hypoglycemic conditions, which in most cases are the result of inadequate diabetes therapy.

In the treatment of patients with diabetes mellitus of any type, the ideal is the maximum possible approximation to the normal state of carbohydrate metabolism. Modern approaches to treatment include three main components:

• the introduction of insulin or tableted hypoglycemic agents,
• dieting,

None of these components alone is sufficient for successful treatment, and the use of hypoglycemic agents or exercise without carbohydrate intake can provoke the development of hypoglycemia and even coma.

All patients, as well as their family members, should be familiar with the signs of hypoglycemic conditions, the rules for their prevention and elimination.

Forecast[edit | edit wiki text]

Hypoglycemic coma, with timely and proper treatment, does not pose such a danger to the patient as diabetic coma, deaths are extremely rare. However, frequent hypoglycemic coma and even hypoglycemic conditions can cause serious cerebral disorders (up to dementia). They are extremely dangerous in people with cardiovascular disorders (they can provoke myocardial infarction, stroke, retinal hemorrhage).

Studying the problem[edit | edit wiki text]

Scientists from the University of Cambridge concluded that dogs can feel the approach of an attack of hypoglycemia in a patient with type 1 diabetes. It turns out that when hypoglycemia occurs, diabetics release isoprene, which causes increased anxiety in dogs.

See also[edit | edit wiki text]

• Hormones
• Glasgow Coma Scale
• Insulin-comatose therapy
• insulinoma

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Types of coma in diabetes mellitus

After some time has passed since the onset of the disease, the human body adapts to some fluctuations in blood sugar levels. However, a very rapid decrease or increase in this indicator leads to irreversible processes in the body. Coma is an acute complication of the disease. Depending on the initial development, the clinic of sugar lumps is divided into the following types:

1. Hyperglycemic - characterized by a strong increase in blood glucose levels. It occurs more often in patients with type 2 diabetes.
2. Hypoglycemic. The main reason is a sharp drop in glucose levels.
3. Ketoacidotic. Due to the lack of insulin, the body receives a lack of energy through the process of splitting fats. As a result, an excess amount of ketone bodies (acetone and acids) is formed, which affect the nervous system. As a result, he develops a state of coma.
4. Hyperlactacidemic. Lactic acid accumulates in tissues and blood in violation of metabolic processes and the liver does not have time to remove such volumes from the body. In this connection, a coma develops, which is the rarest of all types, but causes the most severe conditions for patients.
5. Hypermolar. This type of coma is more common in older people. It occurs due to impaired metabolic processes against the background of a very high level of glucose in the blood. It rarely develops in children.

Hyperglycemic coma can develop both in adults and in children with diabetes mellitus and who have not received proportionate therapy. The reason may be a missed next insulin injection, causing a shortage of this protein hormone. In this case, the metabolic processes in the body are disturbed. Coma can develop regardless of the type of diabetes, even if the disease has not even been diagnosed. The consequences can be severe.

Causes

The diagnosis of diabetes mellitus is a serious disease and must be treated with full responsibility. Indeed, to maintain a normal lifestyle, it is required to monitor the level of glucose in the blood and follow all the doctor's instructions. Failure to comply with these requirements may lead to undesired results. So, both a mistake and forgetfulness can lead to the development of hyperglycemic coma. Here are the reasons why such an unforeseen situation may occur:

• an untimely diagnosis
• delayed administration of the next dose of insulin,
• consequences of not taking an insulin injection,
• incorrectly selected dosage of insulin when prescribed,
• changing types of insulin
• gross disregard for the principles of the diet in diabetes,
• concomitant serious diseases or surgery in the presence of diabetes mellitus,
• stress.

signs

The development of hyperglycemic coma occurs gradually - it can be several hours or days. In children, it develops during the day. The following symptoms precede it:

• constant headache,
• intense thirst,
• weakness and drowsiness
• an increase in the daily amount of urine,
• rapid breathing,
• nausea and vomiting.

12-24 hours after the first signs appear, the condition worsens, apathy for everything appears, urine completely ceases to be excreted, the smell of acetone from the mouth and shortness of breath appear. The person's breathing becomes frequent with deep and noisy sighs. After some time, there is a violation of consciousness, followed by falling into a coma.

In children, it is not difficult to determine who. It is difficult to prevent it. To do this, parents must constantly monitor the child. Signs and consequences of hyperglycemic coma in children are almost the same as in adults. If an adult himself can assess his condition, then such an action instead of a child should be performed by parents.

Symptoms

In addition to partial or complete impairment of consciousness and the smell of acetone, there are a number of other symptoms by which these conditions are diagnosed:

• redness of the face,
• decreased muscle tone,
• low blood pressure,
• the pulse becomes thready and frequent,
• skin becomes cool
• the tongue is coated with a dark brown color.

Urgent care

Insulin-dependent patients are aware of the possibility of deterioration. When a hyperglycemic coma develops, emergency care should be provided immediately. If the patient is conscious, it is required to find out if he has insulin with him and provide all possible assistance in performing the injection. If the drug was not with you, then first aid will be provided by the arriving brigade.

If there is a loss of consciousness, help with hyperglycemic coma consists in laying the patient in a comfortable position, and turning his head to one side to prevent choking with vomit, and also to avoid falling of the tongue. Call an ambulance.

Treatment is carried out in a hospital. First aid is the provision of oxygen therapy. Then the treatment is carried out by simultaneous replenishment of fluid and the introduction of insulin according to special schemes, the development of which used a certain algorithm.

Hypoglycemic coma

This type of coma develops very quickly, so its appearance in children is especially dangerous. As a result, it is necessary to act quickly after the diagnosis is made. Some diabetics who are short-term sick have individual sensitivity to insulin. She can be very tall. Their treatment requires an individual approach, and this must be taken into account with a sharp drop in blood sugar when first aid is provided.

Coma with hypoglycemia can be caused by the following reasons:

• no one taught the diabetic how to prevent a coma when the primary symptoms appeared,
• excessive drinking,
• ignorance of their correct dose of insulin or its administration was not accompanied by the intake of carbohydrates,
• an overdose of pills that cause the body to produce internal insulin.

Symptoms of hypoglycemia

The primary symptoms of hypoglycemic coma are as follows:

• pale skin,
• increased sweating,
• in the hands and feet a feeling of trembling,
• increased heartbeat,
• unable to concentrate
• really want to eat
• anxiety,
• nausea.

With these symptoms, you need to eat several glucose tablets. The first manifestations of hypoglycemic coma in children are similar, they need to drink sweet tea, treat them with candy or give a piece of sugar.

Secondary symptoms indicating an approaching state of hypoglycemic coma:

• severe headache and dizziness,
• feeling of weakness
• feeling of fear, reaching panic,
• a person starts talking, there are violations of visual perception of images,
• trembling in the limbs, convulsions.

These signs in children without adequate assistance lead to convulsions of the masticatory muscles and rapid loss of consciousness. Especially dangerous is the state of hypoglycemic coma in adults, which occurs after taking a large amount of alcohol. In this case, all the symptoms confirm that the person is just drunk. At this time, alcohol blocks the work of the liver for the synthesis of glucose. There is a decrease in blood sugar levels.

Diabetes patients are usually treated by administering insulin before meals. However, there are reasons when it is not possible to eat.

In this case, you need to eat a piece of sugar or candy to avoid hypoglycemia.

When treating patients, it is necessary to learn to distinguish signs of hypoglycemia from hyperglycemia. This is necessary in order not to inject glucose instead of insulin, or vice versa.

Emergency treatment in the hospital begins with intravenous glucose, and then it is administered by drip. In order to prevent cerebral edema, injections of diuretics are made. They also perform oxygen therapy.