Diabetes mellitus has a large number of acute and chronic complications that arise against the background of the lack of timely therapy, the action of concomitant adverse factors, insulin therapy disorders. Hyperglycemic coma refers to acute complications. Pathology is triggered by a critical insufficiency of insulin in the blood or other factors (in type 2 disease) and high levels of sugar as a result.
Hyperglycemic condition is characteristic of type 1 disease, when blood sugar rises to 20 mmol / l. In the case of an insulin-independent form, it may develop in the case of the addition of the cell death of the islets of Langerhans-Sobolev against the background of age-related changes, but this rarely happens. Coma is considered one of the most dangerous complications, because it requires proper differentiation, emergency care and hospitalization until the patient’s state is fully stabilized.
Etiology of the condition
The reasons for the development of hyperglycemic coma are as follows:
- the presence of diabetes, but the man did not guess about it;
- lack of proper therapy;
- violation of insulin therapy or the introduction of an insufficient dose;
- failure to follow the rules of low-carb diets;
- taking hormonal or diuretic drugs on the background of diabetes without the supervision of a specialist;
- infectious diseases;
- stressful states, neurosis;
- postoperative period.
The correct calculation of insulin dose is a preventive measure for the development of a hyperglycemic state.
The last three points should be combined with recalculation of the insulin dose, since the need for a hormonally active substance increases during the background of operations or infectious processes.
Hyperglycemic syndrome may appear in a pregnant woman on the background of gestational diabetes. Causes - lack of awareness of the presence of the disease, untimely administered insulin dose, the appearance of comorbidities.
There is a certain contingent, in whose representatives the risk of a hyperglycemic crisis is higher than in other patients. These patients include:
- those who have chronic illnesses;
- women in the period of carrying a child;
- postoperative patients;
- alcohol abusers;
- seniors suffering from memory problems;
- obese patients;
- children breaking a low carbohydrate diet (secret from their parents).
Varieties of coma
Diabetic pathology, accompanied by hyperglycemia, has several types:
- hyperosmolar coma;
- lacticidecidemic coma.
The stage of decomposition of the "sweet disease" type 1, which develops against the background of absolute insulin deficiency. Lack of timely assistance can cause ketoacidotic coma and death.
Insulin deficiency is accompanied by a parallel increase in secretion and release of catecholamines, cortisol and glucagon. The liver increases the scale of self-production of glucose, but its consumption by cells and tissues is disturbed. Sugar level rises sharply. Insulin deficiency and a large amount of cortisol leads to the fact that a huge amount of fatty acids circulates in the blood, which are oxidized to ketone bodies.
The presence of acetone in the urine is one of the main signs of ketoacidosis.
The level of acetone increases, there is a violation of the ketone metabolism. Due to the fact that urine is trying to remove a large amount of sugar, electrolytes, minerals, and water “go” along with it.
The complication of the insulin-independent form of the disease. It develops against the background of severe dehydration and high blood sugar levels without signs of absolute insulin deficiency. Accompanied by the risk of death.
Hyperosmolar coma occurs in older people who consume little fluid. A huge role is played by the presence of concomitant chronic complications in the form of angiopathy, cardiosclerosis, and cerebral circulation disorders.
Lactic acid coma
Appears in those patients who take glucose-lowering drugs. The result of a lack of insulin becomes a blockade of lactate utilization by the muscular system and the liver. This leads to a high amount of lactic acid in the blood and serious metabolic disorders.
Symptoms of coma
Clinic condition depends on the mechanism of pathology. It is characteristic that the symptoms do not manifest themselves in the form of abrupt changes, but appear gradually.
Patients complain about the following clinic:
- strong thirst, feeling of dry mouth;
- excessive urination;
- weight loss;
- abdominal pain, not having a clear localization;
- signs of dehydration;
- a characteristic smell of acetone or a "fruity" smell emanates from the mouth;
- disturbance of consciousness.
Precursors of ketoacid coma - the first signal of the need for medical care
On examination, you can determine the decrease in muscle tone, rapid heartbeat, decrease the tone of the skin. Breathing becomes frequent, noisy and deep. Seizures of vomiting may occur. If there is no help, then excessive urination is replaced by its absence, vomiting becomes multiple and intense. Body temperature drops to 35-35.5 degrees, the tone of the eyeballs decreases.
If the patient still does not receive the necessary first aid, the blood pressure drops sharply, the person loses consciousness, there is no reaction to all sorts of stimuli. After the development of coma, the lethal outcome develops after a day, if for some reason the necessary assistance in the hospital is not provided to the patient.
More details about the symptoms and signs of hyperglycemic coma can be found in this article.
The following clinical picture develops:
- dry mucous membranes;
- nausea, bouts of vomiting;
- lower blood pressure;
- pulse frequent, weak;
- convulsive seizures;
- characteristic smell of acetone is absent.
Pathology develops acutely over several hours. There is pain in the muscles, behind the sternum, drowsiness, or, conversely, insomnia. Over time, progressing pain in the stomach and bouts of vomiting. Breathing is noisy, frequent, loud. The patient loses consciousness, body temperature decreases, anuria appears.
The presence of polyuria and high thirst for this type of condition is not characteristic, although signs of lactic acidosis may appear in 20% of patients against the background of other types of hyperglycemic coma.
Pathology in a child
Hyperglycemic coma in children is a complex condition in which delaying care can cost the patient life. Hyperglycemia with the development of ketoacidosis is characteristic of young patients. The etiology of development is similar to the causes of the same condition in adults, but instability at the level of mental health, emotional lability and hormonal changes are added.
Self-monitoring of glucose level is a diagnostic criterion that allows you to choose the right tactics to assist
Kids are not able to explain their feelings, which leads to a dramatic development of a vivid clinical picture. Diagnosis, treatment and emergency care are fully consistent with the same processes for adult patients.
The possible consequences of the development of the precomatose state and coma are quite serious:
- tongue dropping;
- choking gag;
- failure of all metabolic processes;
- development of paresis, paralysis;
- impaired mental abilities and cognitive functions;
- myocardial infarction;
- vascular thrombosis with the further development of gangrene.
Differential diagnosis of the condition is based on the examination of the patient, laboratory indicators.
Diabetic ketoacidosis is characterized by indicators:
- blood sugar above 17-23 mmol / l;
- blood pH level is in the range of 7-7.3;
- the presence of acetone in the urine +++;
- increased levels of leukocytes (the higher the level of ketone bodies, the more pronounced leukocytosis);
- the amount of sodium is below normal;
- calcium levels are elevated.
When hyperosmolar coma:
- blood glucose level is above 30-40 mmol / l;
- ketonuria is insignificant;
- osmolarity is higher than 350 mOsm / kg (with a norm of 285 to 295 mOsm / kg);
- blood pH above 7.3.
Lactic acidosis is accompanied by the following indicators:
- the level of lactic acid is more than 2 mmol / l (the norm is up to 1.4 mmol / l);
- the ratio of lactate and pyruvate is disturbed;
- bicarbonate level is reduced by 2 times;
- ketonuria is absent;
- blood pH below 7;
- glycemia is negligible.
Principles of treatment and emergency care
In the absence of time for laboratory diagnosis, you can check the level of sugar and ketone bodies in the urine at home. The amount of glucose is determined by a glucometer, the level of acetone is determined by rapid test strips that change color. Such strips can be purchased at any pharmacy.
Test strips for determining the level of acetone in the urine - home "helpers" diabetic
If a person is conscious, it is necessary to clarify whether he uses insulin therapy. If the answer is positive, you should help him inject the drug, call an ambulance and give him a drink of water. Before the arrival of the physicians, the patient must be put on his back, and his head turned to the side so that in case of deterioration he does not choke on vomit or the tongue does not fall. In the presence of removable dentures, they must be removed.
The patient is warmed, monitor heart rate and pressure. When cardiac arrest or breathing is necessary resuscitation. Do not leave the patient alone.
More information about the processes of emergency care in hyperglycemic coma can be found in this article.
Algorithm and tactics of emergency medical care:
- Introduction of insulin.
- Intravenous saline in order to stop the symptoms of dehydration, and sodium bicarbonate solution of 2.5% concentration to restore electrolyte balance.
- To restore the proper functioning of the cardiovascular system, cardiac glycosides, cocarboxylase, and vitamin C are used.
Infusion therapy is one of the steps to help
Tactics for hyperosmolar coma
Treatment for this type of hyperglycemia has some peculiarities:
- It requires a large amount of drugs used to restore the level of fluid in the body;
- the number of solutions containing potassium, increase by 2 times;
- the amount of insulin required for administration is less than in the case of ketoacidosis;
- it is necessary to lower sugar level slowly;
- bicarbonate is not used.
Elimination of lactic acidosis
The treatment also has a number of features that are distinguishable from ketoacid coma care:
- insulin is administered intravenously on glucose;
- at blood pH less than 7, hemodialysis or peritoneal dialysis is used.
Prevention of hyperglycemic condition requires constant self-monitoring of the glucose level in the body, the timely introduction of insulin in a properly selected dose. It is necessary to avoid the effect of stress on the body, to increase the level of immunity in order to prevent the occurrence of infectious processes.
The role of the nurse in prevention is to explain to the parents of the sick child that it is necessary to constantly monitor the diet, remind children that they like to break the established rules secretly from their parents. Compliance with the recommendations and advice will prevent the development of acute complications.