Hypoglycemic coma

Description:

Hypoglycemic coma — sharply arising morbid condition which is shown reaction of a nervous system in a certain sequence (bark of big hemispheres → a cerebellum → subcrustal and diencephalic structures → the vital centers of a myelencephalon) connected with falling or sharp difference of level of a glycemia (concentration of carbohydrates in a blood plasma). The coma develops sharply. Sometimes the short-term period of harbingers is so small that the coma begins almost suddenly — within several minutes there comes the loss of consciousness and even paralysis of the vital centers of a myelencephalon.

Thus, the hypoglycemic coma — extreme extent of manifestation of a hypoglycemia, develops at bystry decrease in concentration of glucose in a blood plasma and sharp falling of utilization of glucose a brain (most often — the result of discrepancy of a dose of the entered insulin or is much more rare than sulfanamide drugs and the arriving food). The symptomatology of the hypoglycemia preceding a stage of a hypoglycemic coma is very various and caused by two main mechanisms:

    * reduction of content of glucose in a brain (neuroglycopenia) — various behavior disorders, neurologic manifestations, disturbance and a loss of consciousness, spasms and, at last, a coma are characteristic;
    * the reactions connected with excitement of sympaticoadrenal system — diverse vegetative disturbances, tachycardia, a vasospasm, pilomotor reaction, sweating, feeling of tension, concern, fear are characteristic.

Symptoms of the Hypoglycemic coma:

As a rule, develops suddenly. At an easy initial hypoglycemia the patient has a feeling of heat, trembling of hands and all body, sometimes a headache, hunger, the increased perspiration, a heart consciousness, the general weakness. Initial symptoms of a hypoglycemia usually easily are eliminated with timely reception of carbohydrates — all persons receiving an insulin therapy have to carry with themselves glucose tablets (pieces of sugar, candy, juice) on a case of a hypoglycemia and timely to use them.

At treatment by drugs of insulin of the prolonged action (action peak — evening and night hours) hypoglycemic reactions are possible in the second half of day and at night. If expressed to a hypoglycemia develop at night, in a dream, they long time can remain unnoticed. The dream becomes superficial, alarming, dreadful dreams are frequent. In a dream children cry, shout, and when awakening confusion of consciousness and retrograde amnesia is noted. After such nights patients for all day remain sluggish, whimsical, irritable, gloomy and apathetic. In the morning patients complain of weakness, some — of dreadful dreams. The glycemia on an empty stomach can be in the morning high (a "reactive" glycemia on night falling of level of sugar in blood).

The patient in a hypoglycemic coma is pale, skin wet, is noted tachycardia, even breathing, turgor of eyeglobes is usual, language wet, there is no acetone smell, the muscle tone is raised. If help is not given, in process of deepening of a hypoglycemic coma breath becomes superficial, arterial pressure decreases, bradycardia, a hypothermia is noted, the muscular atony, hypo - and an areflexia develops. Reaction of pupils to light and lid reflexes are absent.

If the initial stage of a hypoglycemia remains not distinguished, the condition of the patient sharply worsens — there are spasms of various groups of muscles, a lockjaw, the general excitement, vomiting, oppression of consciousness develops a hypoglycemic coma. Glucose in urine usually is not defined, reaction of urine to acetone can be positive or negative, depending on the previous extent of compensation of carbohydrate metabolism.

Hypoglycemia can develop also against the background of a dekompensirovanny current of a labile diabetes mellitus with ketoacidosis. In response to a hypoglycemia release of kontrinsulyarny hormones kompensatorno increases that promotes developing of ketoacidosis, a diabetes mellitus decompensation, disturbance of a tone of vessels (pressor effect of catecholamines), development of tromboembolic episodes.

At it is long the ill persons with a chronic hyperglycemia symptoms of a hypoglycemia can be observed at normal levels of a glycemia, in the absence of absolute decrease in level of glucose (at 3,3 … 6,6 mmol/l, and sometimes above). Such states come at the considerable, quickly coming differences of levels of a glycemia more often (for example, bystry decrease with 18 … 19 mmol/l to 7 … 8 mmol/l).

Reasons of the Hypoglycemic coma:

The hypoglycemic coma develops at patients with a diabetes mellitus, in most cases, at discrepancy of a dose of the entered insulin or drugs of sulphonylurea and the arriving food, especially carbohydrate. At a diabetes mellitus the hypoglycemic coma develops considerably more often than ketoatsidotichesky.

Usually a hypoglycemia and hypoglycemic comas arise at patients with heavy, extremely labile forms of an insulin-dependent diabetes mellitus at which it is impossible to establish the external reason of sudden increase in sensitivity to insulin. In other cases long breaks between meals, the raised exercise stresses, vomiting, a diarrhea and other morbid conditions happen the provocative moments. The abnormal liver functions accompanying a diabetes mellitus, intestines, the endocrine status, development of a renal failure can dispose to the expressed gipoglikemiya. More often the hypoglycemic coma develops at excess administration of insulin that can occur in the following cases:

    * a dosage error (concentration of drug of insulin, for example the syringes U100 instead of U40, that is is 2,5 times more appointed, or incorrectly gathered insulin dose in the syringe),
    * an error of administration of drug (not under skin, and intramusculary) — a long needle, or intentional intramuscular introduction for the purpose of acceleration and strengthening of effect of hormone,
    * rejection of carbohydrates after introduction of a dose of short insulin ("forgot to have a bite" — the second breakfast, an afternoon snack or the second dinner at peak of effect of drug of insulin of short action),
    * "not planned" physical activity against the background of lack of additional reception of carbohydrates: entered insulin → "forgot" to eat (did not eat additional carbohydrates for ensuring unusual physical activity) → went by bicycle [ski walk, playing soccer, the pool, a skating rink and so on] → a hypoglycemia → a coma,
    * the massaging of the place of an injection of insulin (intended — with the purpose to accelerate effect of drug of insulin of short action or accidental — during driving the bicycle the insulin injection made in a hip),
    * release of a large amount of active hormone at a rupture of a complex insulin antibody,
    * against the background of alcohol intake,
    * in the presence of fatty dystrophy of a liver,
    * against the background of a chronic renal failure,
    * on early durations of gestation,
    * suicide actions,
    * insulin shocks in psychiatric practice and so on.

At persons with a diabetes mellitus the hypoglycemic coma can be result of overdose of insulin, in particular at removal of the patient from a condition of ketoacidosis.

Development of heavy hypoglycemic reaction is possible against the background of alcohol intake to which antihyperglycemic action practically do not pay attention, considering only carbohydrates as a part of alcoholic beverages by drawing up a diet). Alcohol oppresses synthesis of glucose from not carbohydrate raw materials in a liver, thereby increasing the frequency of gipoglikemiya at patients by insulins therapy. The more it is drunk alcohol, the oppression of a gluconeogenesis therefore a hypoglycemia can arise even in several hours after alcohol intake is more long.

Low concentration of glucose in blood is registered if:

    * glucose is removed from blood with greater speed, than soaked up in intestines or synthesized by a liver,
    * disintegration of a glycogen and/or synthesis of glucose from not carbohydrate raw materials in a liver cannot compensate glucose elimination speed,
    * above-mentioned factors are combined.

Quite often approach of compensation of a diabetes mellitus increases sensitivity of peripheral fabrics to insulin that demands timely reduction of a dose of the hormone entered from the outside.

Sulfanamide drugs extremely seldom can cause hypoglycemic reactions, preferential they can arise at elderly patients at a diabetes mellitus combination to diseases of kidneys, a liver or against the background of heart failure, and also at starvation or a hyponutrient. Use of some medicines in combination with streptocides can provoke coma development. For example, acetylsalicylic acid and other salicylates, reducing binding of streptocides proteins of a blood plasma and lowering their excretion with urine, create conditions for development of hypoglycemic reaction.

Treatment of the Hypoglycemic coma:

It was noted above that the hypoglycemic coma develops suddenly, therefore, as well as for any coma, treatment has to be urgent. The main medical actions are carried out at a pre-hospital stage, and only at their unsuccessfulness continue therapy after hospitalization.

    * Begin to enter glucose into the victim's organism. More often it is done by the relatives or friends acquainted with the nature of a disease; the police officers who found the DIABETES card in a pocket of the victim or psychiatric crews which unfairly are called in similar situations.

If there is an opportunity struyno enter into a vein 40% glucose solution (20 — 100 ml) to the patient's exit from a coma. In hard cases apply adrenaline (1 ml of 0,1% of solution under skin) or glucocorticoids intravenously or intramusculary or a glucagon according to the enclosed instruction.

If there is no opportunity to make an injection, charge to someone to call the ambulance car and start administration of glucose in all available ways:

  1. until the deglutitory reflex is kept — to the victim allow to drink solution of glucose or any sweet juice (grape, apple and similar, give preference to juice without pulp, drinks on sweeteners are useless here),
  2. if the deglutitory reflex is absent, and pupils wide and do not react to light — drip glucose solution under the victim's language as even in a coma at frustration of a microcirculator bed ability to acquire glucose from under language remains, but do it with care — drip small amounts that the victim did not choke (in a deep coma of people loses a deglutitory reflex). Manufacturing firms produce glucose in the form of gel — in the presence of sufficient experience, it is possible to use gel or honey which chemical formula is identical to sucrose.

Before establishment of nature of coma, determination of level of glucose in blood administration of insulin is inexpedient and it is even dangerous. So, at a hypoglycemic coma insulin aggravates weight of frustration, its introduction can be fatal. Do not enter at all insulin (usually the syringe is found in the victim's pocket) as glucose will save life or the hormone here entered insulin will not do much harm (at a diabetic coma the amount of glucose which will be used by the victim, significantly will not change a situation — too large volume of cultivation — at the adult is these are 5 liters of the circulating blood and the milliliters entered in addition are scanty), and at a hypoglycemic coma sharply reduces chances of an organism to cope independently with a situation. By the way, some manufacturing firms equip the means of administration of insulin with automatic blocking. It becomes for an exception of a possibility of "unconscious" administration of insulin.

Indications for urgent hospitalization.

    * at repeated intravenous administration of glucose the hypoglycemia is not stopped and consciousness of the victim is not recovered;
    * the hypoglycemic state is stopped at a pre-hospital stage, however the symptoms of cardiovascular, cerebral disturbances, neurologic frustration not inherent to a usual condition of the patient remain or appeared;
    * development of repeated hypoglycemic reactions soon after the held medical actions.