What Is a Diabetic Coma?

On physical examination, pay attention to the degree of dehydration, deep and rapid breathing, exhaled ketone smell and peripheral circulation failure.

Diabetic coma

Diabetic coma is a group of clinical syndromes characterized by disturbance of consciousness caused by diabetes. It includes 2 clinical types, namely diabetic ketoacidosis and diabetic non-keto coma (hypertonic coma). They are the most common and most dangerous comorbidities of diabetes. If not treated in time, they often lead to death.

Chinese name: Diabetic coma
Foreign name: Diabetic coma

Cause: Diabetes causes disturbance of consciousness
Signs and symptoms: Dehydration, deep and rapid breathing, etc.

Diabetic coma symptoms signs

On physical examination, pay attention to the degree of dehydration, deep and rapid breathing, exhaled ketone smell and peripheral circulation failure.

1. The medical history is mostly elderly, mostly in the age of 50 to 70, the prevalence of men and women is about the same. About half are known to have diabetes, about 30% have a history of heart disease, and about 90% have kidney disease. Types of diabetes: Most are type 2 diabetes; a few can be type 1 diabetes, mostly coexisting with DKA; occasionally it can occur in patients with diabetes such as hypercortisolism, acromegaly and so on.

2. Slow onset. From days to weeks before the onset of symptoms, patients often have clinical manifestations of gradually increasing symptoms of diabetes, including polydipsia, polyuria, fatigue, dizziness, lack of appetite, and vomiting.

3. Dehydration and peripheral circulation failure patients often have severe signs of dehydration, showing dry skin and reduced elasticity, sunken eyes, dry tongue, and longitudinal cracks. When the patient has peripheral circulation failure, the pulse is fast and weak, the jugular vein is incomplete in the supine position, orthostatic hypotension, and the systolic blood pressure drop after standing is 1.3 kPa (10mmHg) lower than that in the supine position. Many patients were already in shock at the time of consultation, but due to severe dehydration, no cold sweat was found during physical examination. Although some patients are severely dehydrated, the hyperosmotic state of plasma prompts the intracellular fluid to go out, supplementing blood volume, which may cover the severity of dehydration and keep blood pressure normal.

4. Nervous system symptoms and signs About half of the patients are unconscious, and one third are in a coma. Some patients are misdiagnosed as a cerebrovascular accident, and even mistakenly input hypertonic glucose solution or dehydrating agent, which makes the disease worse. The degree of consciousness disturbance in HNDC patients is mainly determined by the degree and speed of the increase in plasma osmotic pressure. It is also related to the level of blood glucose, but not to the degree of acidosis. Some people abroad have found that when the effective plasma osmotic pressure of patients exceeds 320mmol / L, mental symptoms such as indifference and drowsiness can occur; when it exceeds 350mmol / L, 40% of patients may have confusion or coma. However, there are some patients whose plasma effective osmotic pressure is slowly rising. Although they have exceeded 400mmol / L at the time of consultation, the patient is still awake.

Nervous system signs: such as epilepsy, transient hemiparesis, muscle relaxation or involuntary contraction, aphasia, ipsilateral hemianopia, visual impairment, nystagmus, hallucinations, loss of hemiplegia, positive Babinski sign, and central Fever. These signs suggest that the patient may be related to cerebral cortex or subcortical damage caused by dehydration, blood concentration, or vascular embolism. Most of these changes can be reversed or returned to normal after effective treatment. There are also a few symptoms that can still leave some neurological and mental disorders within a period of time after HNDC correction.

5. Patients with symptoms and signs of onset may have manifestations of pre-existing diseases such as hypertension, kidney disease, coronary heart disease; induced diseases such as pneumonia, urinary system infection, pancreatitis; and complications such as cerebral edema, thrombosis, and vascular embolism which performed. The patient's body temperature is usually normal or slightly elevated. If the body temperature is lowered, it may be accompanied by acidosis and / or sepsis, which should be given sufficient attention.

Causes of diabetic coma

Pay attention to the history of previous diabetes and recent treatments, whether there are acute infections, diarrhea, eating disorders, excessive sugar, no previous diabetes found and misuse of sugar, severe mental stimulation, discontinuation or substantial reduction of insulin, taking large amounts of biguanides Sugar medicine, etc.

1. Stress and infections such as cerebrovascular accidents, acute myocardial infarction, acute pancreatitis, gastrointestinal bleeding, trauma, surgery, heat stroke or hypothermia. Infections, especially upper respiratory tract infections and urinary tract infections, are most often induced. 2. Insufficient water intake decreases the sensitivity of the thirst of the elderly, bedridden patients, patients with mental disorders or coma, and young children who cannot actively take water.

3. Excessive dehydration and dehydration, such as severe vomiting, diarrhea, patients with large area burns, neurological and surgical dehydration treatment, dialysis treatment, etc.

4. High-sugar intake and input, such as a large intake of sugary drinks, high-sugar foods, intravenous infusion of a large amount of glucose when the diagnosis is unknown or missed, complete intravenous hypertrophy, and the use of sugary solutions for hemodialysis or peritoneal dialysis. Happening. Especially in patients with certain endocrine diseases combined with glucose metabolism disorders, such as hyperthyroidism, acromegaly, cortisol, and pheochromocytoma are more likely to be induced.

5. Drugs Many drugs can be incentives, such as the heavy use of diuretics such as glucocorticoids, thiazines or furosemide (fast urine), propranolol, phenytoin, chlorpromazine, cimetidine, glycerol , Azathioprine and other immunosuppressants. Both can cause or aggravate the body's insulin resistance and increase blood glucose and dehydration. Some drugs, such as thiazide diuretics, can also inhibit insulin secretion and reduce insulin sensitivity, which can induce HNDC.

6. Others such as acute and chronic renal failure, diabetic nephropathy, etc., because the glomerular filtration rate decreases, the clearance of blood glucose also decreases. Can also be an inducement.

Diabetic coma diagnostic test

1. Check blood glucose, ketone body, lactic acid, carbon dioxide binding capacity, urea nitrogen, blood pH, blood potassium, blood sodium, blood chlorine, plasma osmotic pressure immediately after admission [or calculate by formula: 2 (Na ++ K +) mmol / L + (glucose mg / d1 ÷ 18) + (urea nitrogen mg / d1 ÷ 2.8)], urine sugar and ketone body, and then repeat the test every 1 ~ 4h until the blood biochemical test value returns to normal.

2. Renal function test, ECG test. Check urine routine and urine ketone body.

3. Classification

The blood glucose was significantly increased, blood ketones were increased, blood carbon dioxide binding power and pH value were decreased, and urine ketone positive was diabetic ketoacidosis coma.

Extremely high blood glucose (approximately 1000 mg / d1 or higher), high blood sodium, high plasma osmotic pressure, and no obvious ketoacidosis, is a highly permeable non-ketogenic coma; common in elderly patients.

Due to shock or taking biguanide hypoglycemic drugs, blood lactic acid increase, acidosis, generally no hyperglycemia, no ketosis, is diabetic lactic acidosis.

Treatment options for diabetic coma

1. According to the coma nursing routine, blood pressure is measured once an hour

2. Treatment of diabetic ketoacidosis coma

(1) Injection of ordinary insulin

In order to prevent the blood sugar drop too fast, acidosis to correct too fast during the treatment process, leading to brain edema and even death, you can apply the "low-dose insulin" treatment plan: the first intravenous drip of RI (in normal saline), the dosage is 5 Calculated at 10U / h (0.1U / kg? H), with intramuscular injection of 10-20U. Strictly observe the blood glucose situation. When the blood glucose drops to 13.9mmol / L (250mg / d1), the insulin will be changed to

symptom 2h subcutaneous injection once, the dosage is urinary sugar ++++ 16U, +++ 12U, ++ 8U, + 4U. If blood sugar does not drop after 2 to 3 hours of treatment with insulin and fluid, there may be insulin resistance and the hourly insulin dose should be doubled. Hypoglycemia should be avoided during treatment with too much insulin, too fast, or due to excessive blood glucose drop, leading to cerebral edema and hypokalemia.

(2) Correction of dehydration, electrolyte disturbance, acidosis

Replenishment of normal saline: 2000ml fluid for the first 2 to 4h, about 4000ml on the first day. The elderly and those with heart and kidney dysfunction should not be too fast. When the blood sugar drops below 13.9mmol / L (250mg / d1), use 5% glucose solution, or 4/5 parts of 5% glucose solution and 1/5 part of normal saline. When patients can eat, encourage liquid or semi-liquid food.

Potassium supplementation in time: If the blood potassium level is low or normal, and the urine output is sufficient, potassium chloride will be dripped at the rate of 1 1.5g / 500ml at the beginning of treatment, and potassium supplementation will be 6-9g on the first day. Those with hyperkalemia before treatment should pay attention to potassium supplementation 3 to 4 hours after treatment. Potassium supplementation should be carried out under ECG monitoring, or blood potassium measurement 2 to 3 hours to prevent the production of hyperkalemia. When blood potassium is above 5mmol / L, potassium supplementation is terminated.

Correct acidosis: no alkaline agent is used when blood pH> 7.15, 150ml of 5% sodium bicarbonate is used when pH <7.0, half amount is used when pH7.0 7.15.

3. Treatment of hypertonic non-ketogenic coma

(1) Correction of hypertonic dehydration and electrolyte loss: Immediately instill physiological saline and use 2-3L within the first 2 hours. Later, a considerable amount of warm water can be injected from the gastric tube; if blood volume recovers, blood pressure rises to normal , And the osmotic pressure does not drop, especially when hypernatremia, can be infused with hypotonic solution (0.45% or 0.6% sodium chloride) 500 ~ 1500ml / d; until the blood glucose drops to 16.7mmol (300mg / d1)

Diabetic coma In the following, use 5% glucose solution intravenously. When potassium is less than 5mmol, potassium supplementation is started, and the potassium is maintained at 4-5mmol / L.

(2) Insulin: the dosage should be smaller than that of ketoacidosis coma (4 6U / h). Generally, ordinary insulin is used. Please refer to the above-mentioned "low-dose" regimen and intravenously. But emphasis is placed on early diagnosis and treatment. The blood glucose should not be lower than 13.9mmol / L (250mg / d1) within 24 ~ 48h.

(3) Remove incentives for treatment, and pay attention to monitoring vital signs, blood, urine sugar, electrolytes, BUN, etc.

4. Lactic acidosis treatment

(1) Actively resist shock, improve microcirculation perfusion, and correct tissue hypoxia.

(2) Actively correct acidosis. Intravenous drip of 1.5% or 5% sodium bicarbonate can be given. Large amounts are used. Generally, 200% to 1000ml of 5% sodium bicarbonate is used. Strive to increase the blood pH to normal within 8 hours. Available 100mmol. Take care to avoid hypokalemia. The elderly and those with heart and kidney dysfunction must use dialysis. Trometamol (THAM) can also be used, but sodium lactate is contraindicated.

(3) Those with hyperglycemia should be treated with RI; those without hyperglycemia should be given glucose at the same time.

5. Stop using biguanide drugs

6. General treatment should be controlled first

Those with infection are quickly controlled with antibiotics. Those with shock actively take anti-shock measures. If necessary, they can be transfused with plasma or whole blood, and noradrenaline should be avoided.

Diabetes Coma Safety Tips

1. If the patient is conscious and can swallow, then the most effective way for hypoglycemic coma is to let the patient drink sweet water or eat sugar cubes, sweet cakes and the like

2. An effective method for hyperglycemic coma is to drink some salted tea or low-salt tomato juice.

3. If the patient's consciousness has been lost, the patient should be leveled and the collar should be untied to ensure that the airway is unobstructed.

Diabetic coma care

1. When a diabetic patient is in a coma, if it is not rescued in time, it is likely to be life-threatening. Nursing staff and family members must observe the patient's condition at any time;

2. Remember the amount of fluid in and out of the patient, such as the amount of water or infusion, urine volume, etc .;

3. When the patient is out of danger and consciousness is restored, he should actively treat diabetes, adjust his diet, use insulin reasonably, make his metabolism normal, and avoid the recurrence of diabetic coma;

4. Diabetes is a chronic disease that requires long-term treatment. Patients and their families must eliminate their concerns, build confidence, and learn about diabetes, which is of great benefit to patients;

5. In order to prevent accidents, diabetic patients should always carry a card with the words "have diabetes", and the card can also record some treatment methods and patient names, addresses, etc., in order to provide for others and doctors in case of sudden loss of consciousness reference.

First aid measures for diabetic coma

1. First find out what caused the coma, and distinguish between a hyperglycemic coma or a hypoglycemic coma.

2. When hypoglycemia occurs, the patient first feels dizzy, dizzy, hungry, shaking hands, and sweating cold

diagnosis Wait, further development will appear irritability, convulsions, mental disorders, and finally fall into diabetic coma. If the patient can still swallow, for hypoglycemic coma, let the patient drink sugar water or eat sugar cubes, sweets, etc.

3 For hyperglycemic coma, the patients can be asked to drink some salted tea and sent to the hospital for rescue.

4 If it is difficult to determine the cause of coma in diabetic patients, do not take measures blindly, because the treatment of coma caused by two causes of hyperglycemia and hypoglycemia is completely opposite.

5. If the patient's consciousness has been lost, the patient should be leveled, the collar should be untied to ensure that the airway is unobstructed, and immediately sent to the hospital for rescue.

Four types of coma in preventing and treating diabetes

During the treatment of diabetes, there may be four critically ill and severe cases of diabetic ketoacidosis coma, non-ketogenic hypertonic diabetic coma, lactic acidosis coma, and diabetic hypoglycemia coma due to mistreatment or misregulation of life. If not rescued in time, there will be life concerns.

The diabetic ketoacidosis coma is due to severe insulin deficiency, which accelerates the decomposition of fat, and the ketone bodies produced by the oxidation of fatty acids in the liver increase significantly, leading to ketone body accumulation and ketoacidosis. Coma on this basis is called diabetic ketoacidosis coma. It is more common in diabetic patients who suddenly interrupt insulin therapy and newly diagnosed diabetic patients without any treatment. Symptoms include irritability, polyuria, fatigue, fatigue, appetite, nausea, deepening of breathing and then lightening and slowing. There may be rotten apple smell in exhalation, dizziness, headache, and even shock, drowsiness, and coma. Treatment is mainly based on fluid replacement, insulin use, correction of electrolyte disorders and acid-base balance disorders.

Nonketogenic hypertonic diabetic coma refers to severe hyperglycemia, hypertonic state of blood, dehydration, and coma during the course of severe infection, trauma, blood or peritoneal dialysis, use of diuretics or adrenal corticosteroids in diabetic patients. Characteristic illness. Symptoms include high fever and thirst, drinking and urination, fatigue, dizziness, dry skin, reduced elasticity, cracked lips and tongue, sunken eyes, decreased blood pressure and other dehydration manifestations and even shock, shallow breathing, increased heart rate, dizziness, Limbs convulsions, delirium, disorientation, irritability or apathy or even coma, epileptic seizures, hemiplegia aphasia, blindness or nystagmus, positive pathological reflexes, etc. Treatment is based on rapid and massive rehydration, use of insulin, maintenance of water-electrolyte and acid-base balance, and prevention of infection.

medical treatement

Diabetic coma diabetic lactic acidosis coma

Lactic acidosis in diabetic patients is common in patients with severe heart, lung, liver, and kidney disease who mistakenly used biguanide drugs hypoglycemic. Jiangtangling can increase the anaerobic fermentation of sugar and increase the production of lactic acid. When the amount of lactic acid exceeds the liver and muscle uptake and kidney excretion limit, lactic acidosis occurs. Symptoms include nausea, vomiting, abdominal pain, bloating, burnout, fatigue, deepening of breathing, and gradually fall into a coma. The treatment is to stop the drugs that can cause lactic acidosis such as Jiangtangling, use insulin and 5% sodium bicarbonate injection to control infection, correct dehydration and shock, diuretic and acid discharge, correct water and electrolyte disorders, give oxygen and potassium, necessary Hemodialysis or peritoneal dialysis is mainly performed with lactate-free dialysate.

Diabetic hypoglycemic coma is seen in patients with diabetes who over diet, excessive insulin injections, and inappropriate use of oral hypoglycemic agents. Symptoms include hunger and fatigue, dizziness, headache, cold sweats, palpitation, shortness of breath, tachycardia, nausea and vomiting, blurred vision, trembling throughout the body, even mental disorders, abnormal behavior, lethargy, coma in the limbs, and even death. Hypoglycemia can occur during the day or at night. The onset of hypoglycemia during sleep at night can awaken patients from dreams, accompanied by cold sweats, irritability, and tachycardia. If you have symptoms of hypoglycemia, you should monitor your blood glucose in time, enter sugary foods such as syrup, candy, fruits, biscuits, snacks, steamed bread, etc. as soon as possible. Monitor and observe changes in consciousness and deal with them accordingly to avoid accidents.

The main causes of diabetic coma and emergency treatment

Diabetic coma nonketone hyperosmolar coma

This coma is more common in elderly diabetic patients over 60 years of age. The main clinical manifestations are severe dehydration, high blood sugar, high plasma osmotic pressure, and neuropsychiatric symptoms.

Diabetic coma

Hypoglycemia is called when blood glucose is lower than 3 mmol / L. Severe hypoglycemia can cause coma. Common reasons are: too much insulin or oral, hypoglycemic medicine and too little food; exercise increased, but did not increase food intake accordingly.

Diabetic coma ketoacid coma

The reasons are:

1. Diabetic patients stop or reduce insulin too fast, or their condition worsens.

2. Various acute and chronic infections.

3. Stress states, such as trauma, surgery, childbirth, pregnancy, acute myocardial infarction, hyperthyroidism, etc.

4. Eating disorders, eating too much or too little, drinking too much, etc.

Prognosis and prevention of diabetic coma

Diabetic coma prognosis

The mortality of diabetic coma depends largely on the early diagnosis and treatment of comorbidities. About 28% of patients die mainly from hyperosmosis within 48 hours after hospitalization. Therefore, the longer the duration of hyperosmotic state, the higher the mortality. Various comorbidities, especially infections, are the leading cause of advanced death. However, as diabetic coma occurs in the elderly, as pointed out by Arieff et al.

Precaution The treatment is positive and the mortality rate is still high. Therefore, it is important to make every effort to prevent induced diabetic coma. All clinicians are required to be vigilant and avoid all factors that may cause diabetic coma when dealing with elderly patients, regardless of history of diabetes. occur.

Diabetic coma prevention

1. Strengthen the education of diabetes knowledge and health check, early detection and early treatment, elderly people over 50 should regularly check blood sugar. Patients diagnosed with diabetes should take regular medication, control diet, strengthen exercise, and strictly control blood sugar levels.

2. Control various inducing factors, and actively treat various infections. For hemodialysis, peritoneal dialysis, and application of mannitol dehydration, you should pay attention to whether there is dehydration and monitor blood glucose and urine sugar in time.

3. Pay attention to induce drug application, such as diuretics, glucocortisol, propranolol (propranolol) and so on.

Daily prevention of diabetes coma

1. Always pay attention to drinking water, do not limit drinking water

2. Regular life, reasonable living, pay attention to exercise

3. Elderly patients have minor illnesses and need timely treatment

4. Blood glucose monitoring should be strengthened in case of any discomfort

Diabetes Coma Health Tips

1. If the patient is conscious and can swallow, then the most effective way for hypoglycemic coma is to let the patient drink sweet water or eat sugar cubes, sweet cakes and the like

2.An effective method for hyperglycemic coma is to drink a tea with salt or low

Enhance physical fitness Salt tomato juice etc.

3. If the patient's consciousness has been lost, the patient should be leveled and the collar should be untied to ensure the airway is unobstructed

[Nursing measures]

1. When a diabetic patient is in a coma, if it is not rescued in time, it is likely to be life-threatening. Nursing staff and family members must observe the patient's condition at any time;

2. Remember the amount of fluid in and out of the patient, such as the amount of water or infusion, urine volume, etc .;

5. In order to prevent accidents, diabetic patients should always carry a card with the words "have diabetes", and the card can also record some treatment methods and patient names, residential addresses, etc., in order to provide for others and doctors when sudden consciousness is lost reference.