Hypoglycemic coma is a pathological condition of the human nervous system caused by an acute shortage of glucose in the blood for the nutrition of brain cells, muscle and other body cells. The condition of hypoglycemic coma develops quickly, as a result, there is an oppression of consciousness, all vital functions. In case of untimely rendering of the first honey. care is possible for conditions that threaten human life: heart failure, the refusal of the respiratory center in the medulla oblongata.
Hypoglycemic coma is the logical conclusion of prolonged hypoglycemia. Therefore, it is extremely important to be able to recognize the precursor state - hypoglycemia.
Causes of hypoglycemic coma
From the very term it becomes clear that the cause of hypoglycemic coma is prolonged hypoglycemia . Consider the main causes of hypoglycemia.
The most common hypoglycemic coma develops in people with diabetes mellitus. This disease is associated with an inadequate release of the hormone insulin beta cells of the pancreas. Sometimes the secretion of insulin can remain at the normal level, but for unexplained reasons, cells that have insulin specific receptors cease to perceive insulin, which is produced by its own pancreas. This leads to a state of persistent hyperglycemia with a rather pronounced clinical picture: increased appetite, thirst, causing to drink up to six liters of fluid, weakness and malaise after eating, weight loss and other symptoms. This causes people to take exogenous insulin, because otherwise there may be a hyperglycemic coma or other severe consequences.
In addition to insulin-dependent diabetes, there are other forms in which insulin is produced less than necessary, which leads to typical symptoms for diabetes mellitus, but less pronounced or manifested only after consumption of carbohydrate food. For this type of diabetes, treatment usually involves taking insulin secretagogues and a special diet. Sugar-reducing drugs, for example, Glibenclamide, have a number of side effects, and in case of an overdose they can provoke a state of hypoglycemic coma.
When using insulin therapy, doctors give the greatest preference to the appointment of either ultra-short-acting insulin or prolonged ones. Substitution therapy with insulin of ultrashort action is based on the introduction directly when the body's need is greatest - before eating (as the action comes after a while) and at night. It is because of this peculiarity of therapy that there is a rather high probability of provoking a hypoglycemic coma, for example, if after the introduction of insulin before eating, no food was taken.
When using the traditional scheme of insulin therapy (one third of insulin of ultrashort action, the rest is of long duration), the most important condition for a person is strict adherence to a diet. Diet is necessary in order to avoid the development of hyper- and hypoglycemia, as well as hypoglycemic coma. Nutrition is fractional, five-six-time, with all the criteria: nutritional value-requirement, comparison of the number of bread units to the amount of insulin administered.
For some reason, there may be a critical inconsistency between human insulin (the hormone responsible for processing glucose) and the carbohydrate food consumed. In connection with the fact that a sufficient amount of insulin circulates in the body, and there is no glucose in the blood, a state of hypoglycemia develops, capable of provoking such a condition as a hypoglycemic coma. A person, absorbed in their daily worries, may not notice in time the gradually increasing symptoms of hypoglycemia.
In addition, even if the diet is observed, the patient may erroneously or intentionally introduce insulin not according to the rules (not under the skin, but intramuscularly). This leads to a faster absorption and a strong effect of insulin, which will inevitably lead to a state of hypoglycemia and subsequently cause hypoglycemic coma.
Another variant of the violation of the regime and the rules for the introduction of insulin is the use of alcoholic beverages the day before. It has long been established that alcohol interferes with the normal metabolism of carbohydrates (including glucose).
The state of hypoglycemic coma can result in unplanned physical stress without correction of diet and insulin administration. In other words, after the introduction of the hormone was followed by a sharp physical load, for which simply did not have the available amount of energy (which is mostly taken during the processing of glucose).
There are unusual situations when a person who has free access to insulin, suddenly wanted to settle scores with life through an overdose of medicines. Such people manage to be saved if they previously applied for psychological help or on the eve spoke about a similar desire to close people.
For several decades, hypoglycemic coma has been used as a therapeutic shock therapy in psychiatric practice. Insulin-shock therapy, along with electro-convulsive therapy, slows the development of symptoms in patients with severe, rapidly progressive form of schizophrenia and some other mental illnesses. Such procedures are carried out only in a hospital environment after a lengthy preliminary preparation and, of course, they involve a certain risk.
In elderly people with diabetes it is very rare, but still there may be acute hypoglycemia or even hypoglycemic coma in response to the intake of hypoglycemic drugs. Namely, such cases were registered after taking large doses of sulfonylurea derivatives (Glikvidon, Glibenklamid, etc.) and malnutrition during the day.
And of course, one of the causes of hypoglycemic coma is a dosage error, for example, when insulin is injected into a syringe of a different volume and labeling (syringes are used with a standard dosage of 40 and 100 units per milliliter), and as a consequence, a dose that exceeds one-time in 1, 5 - 2 times. In some cases, such an introduction may cause a shock and an almost instantaneous development of coma.
Direct influence on the emergence of the state of hypoglycemia has a pancreatic tumor, the cells of which produce insulin - insuloma. Tumor overgrowth of pancreatic cells with the active islets of Langerhans can bring a lot of trouble to the patient, because it is very difficult to diagnose. Sometimes the secretion of insulin by the tumor reaches critical numbers, causing hypoglycemic coma.
The above reasons can lead both to the sudden development of hypoglycemic coma, and to the gradual development of hypoglycemia, and after - coma.
Hypoglycemic coma symptoms
The clinic of hypoglycemic coma in many patients is usually lubricated, in the first hour few people pay attention to the symptoms. Initial manifestations of lowering blood glucose levels are associated with "starvation" of the brain and related chemical processes in neurocytics and synapses (brain cells), because cells begin to synthesize energy from reserve substances that are absolutely not designed for this purpose. Against the background of weakness, a headache is accumulating , which is practically not removed by anesthetics. Coldness of hands and feet, humidity of the palms and feet are noted. There are "hot flushes" of heat, and in the summer time, presyncope states are possible due to violations of thermoregulation and circulation.
It becomes noticeable pallor and numbness (tingling) of the nasolabial triangle, which always clearly reflects the degree of saturation of the brain with oxygen and glucose. In this state, people are usually aggressive, impatient with criticism. With the growth of hypoglycemia, fatigue increases, the ability to work is noticeably lower, especially in the intellectual sphere. Appears short of breath when walking and light loads. It is possible to temporarily reduce visual acuity until the required level of glucose is restored. With time, trembling of the fingers, and later of other muscle groups, is increasing.
All of them without exception have a strong feeling of hunger. Sometimes it is so pronounced that it is described as a feeling bordering on nausea.
At later stages of hypoglycemic coma development, double vision is possible, the difficulty of focusing the vision, deterioration of color perception (colors appear dimmer or all around in gray tones).
Violations in the nerve center of movement control lead to a decrease in the accuracy of movements, which can lead to accidents at work and at home, at the wheel and during the performance of familiar actions.
If such a condition is caught by a person during a stay in a hospital, it is necessary to tell the nurses and the treating doctor about this. They will do the necessary tests (urine for acetone, blood for sugar) and will begin to treat hypoglycemic coma.
From violations in the cardiovascular system, it should be noted an increasing tachycardia. This is a kind of quantitative violation of the rhythm of the heartbeats. In some cases, tachycardia can reach 100-145 or more beats per minute, and a sense of fear, dyspnea, and hot flushes are added to the palpitation. When you take carbohydrate food or sugar-containing foods (sweet tea, sugar candies, sugar cube), the heart gradually "calms down," the frequency of beats per minute decreases, and other symptoms disappear without a trace.
Symptoms of hypoglycemic coma
Hypoglycemic coma - one of the few conditions that has a lightning-fast development. Symptoms that are characteristic only of hypoglycemic coma should encourage the proper provision of first medical and pre-medical care. Indeed, in a state of coma, the human body is in the line of life and death, and any error in the treatment or emergency care can be fatal.
The predkokatoznoe state has a number of features: a sharp onset of clonic and tonic seizures or epileptiform seizures. It begins with the twitching of the muscles throughout the body and is rapidly amplified to an extreme degree - a convulsive fit. This condition is dangerous because it is completely unpredictable, and a person can become a victim of a car accident, falling from a height.
The state of hypoglycemic coma is due to the response of the medulla oblongata to hypoglycemia: complete loss of consciousness, pupils dilated. At a detailed examination: the skin is pale, cold sticky sweat, the breath is slightly weakened, the blood pressure is normal or increased, the pulse is normal or slightly increased, the knee and elbow reflexes are strengthened.
Consciousness is absent, which is expressed by the lack of response to physical stimuli, for example, slapping on the cheeks, shouting, dousing with cold water and other methods of "awakening". Many cases were recorded when people after exiting the hypoglycemic coma claimed to have seen everything happening around from the side. The official science of this information is not confirmed and are considered too realistic influx of illusions during the unconscious state.
Respiration in the initial stages of hypoglycemic coma is changed slightly. But the most formidable complication is the refusal of the respiratory center. This means that the respiration of the patient (rhythm, uniformity, depth) should be given due attention during transportation or resuscitation. If breathing is superficial, that is, when the mirror is brought to the patient's mouth, there is misting, it is necessary to introduce respiratory stimulants, since, if you miss a moment, you can lose a person.
The clinic of hypoglycemic coma combines many signs of urgent conditions, and only a comparison of all the symptoms in a single picture will help the health worker, the relative or the casual passer-by to provide the right help.
If a person is treated correctly, he comes to consciousness within 10-30 minutes (in the absence of complications of hypoglycemic coma).
Hypoglycemic coma in children
The main principle of development and course of hypoglycemic coma in children is similar to that of adults.
The cause of hypoglycemic coma in children can also serve as incorrect insulin administration, prolonged fasting, non-compliance with rare hereditary diseases (insufficiency of digestive enzymes, glucose intolerance, galactose or fructose intolerance).
In children, hypoglycemia is more difficult to distinguish from a variety of conditions, because children, especially preschool age, often can not describe what exactly bothers them.
With a headache, the child is likely to be whiny, restless. With the syndrome of abdominal pain (abdominal pain, as a reactive manifestation of hypoglycemia) in children, appetite is reduced, food can be completely denied, although hunger is one of the obvious symptoms of hypoglycemia.
At the next stage of hypoglycemia in children they become sluggish, to all indifferent, completely non-contact. All this takes place against the background of previous prosperity. Such changes in the behavior of the child should alert the parents.
As in adults, there is a pallor of the skin, severe trembling of the hands, as well as sweating of the palms. In addition, there are attacks of dizziness , especially along with a pre-fainting condition with a change in body position (with a sharp rise).
It should be borne in mind that children develop all the symptoms much faster, although the clinic for hypoglycemic coma does not differ from that in adults: rapid onset, convulsions, loss of consciousness; typical for coma manifestations: slowing of breathing, heart rate, lowering blood pressure. Lethal outcome or irreparable disturbances in the brain occur more quickly, so the speed and coherence of the actions of people who provide help depends on the life and health of the child.
Treatment of hypoglycemic coma
To treat such a serious condition as hypoglycemic coma, it is necessary to make sure that this condition is coma, and after that this coma is hypoglycemic. The correct diagnosis is of great importance in this case. For example, when suspected of hyperglycemic coma, the early administration of glucose solution can lead to death.
Much depends on whether there are witnesses who could describe a person's behavior before the loss of consciousness, describe his complaints, provide information about the medications that the patient has taken recently. If witnesses verified convulsions, and after a loss of consciousness, preliminary insulin injection or prolonged starvation of the victim, it is safe to start reanimation measures for the diagnosis of "hypoglycemic coma". And if a person has already been found unconscious, there were no traces of the use of medications (insulin or hypoglycemic drugs), then for the beginning it must be delivered to a medical institution where rapid tests for the amount of glucose, acetone, ketone bodies, and already after - treatment.
In the early stages of the development of hypoglycemic coma (in a state of hypoglycemia), the best preventive method of coma is the intake of sweet and carbohydrate food. In this case, do not eat chocolate candy, because they contain a large number of different fats, flavors, flavors of doubtful origin and little glucose. A person suffering from diabetes is best to carry in his pocket several ordinary candies, but not chocolate.
The doctor must necessarily conduct conversations with people suffering from diabetes, especially with children or their parents, the importance of dieting, the mode of taking medicines, and about the proper distribution of physical activity.
Use with caution long-acting insulin. It is recommended to inject under the skin of the thighs or shoulders, since its absorption in these places is slower. A very important task is to conduct a study of the glycemic profile during the day. This will facilitate the task of choosing insulin for administration at night and will enable to prevent hypoglycemia in a dream.
People suffering from type 1 diabetes require a diet with regard to their energy needs. In other words, the amount of incoming calories should be fully used by the body, and the amount of insulin administered should correspond to the carbohydrates consumed. To facilitate caloric counting, patients can use different tables indicating the nutritional value of both individual foods and ready meals. But to calculate the carbohydrate load in the products used grain units. One such unit roughly corresponds to 12 grams of carbohydrates along with dietary fiber. Or 25 grams of plain bread. Bread units are used to self-check diets for diabetes, they are designed to improve the quality of life of diabetics, accusing them of their own health.
To treat hypoglycemic coma, a glucose solution of 10% is used in an amount of 100 to 250 milliliters. This is necessary to maintain a constant level of glucose in the bloodstream. If the patient does not regain consciousness during the infusion of glucose, it is necessary to take measures to prevent cerebral edema - intravenously administer a 15% solution of Mannitol at a rate of 1 to 2.5 milligrams per kilogram of body weight, and after introducing Furosemide (Lasix) 75 - 110 mg intravenously struino. Mannitol is the representative of a group of osmotic diuretics, its action is based on the physical laws of interaction of water molecules and drug substance. It is excreted from the body in an unchanged form with attracted water molecules. Lasix, however, has a specific effect in the renal apparatus, stimulates the formation of urine and its further isolation. It should be administered with great care, as it can cause profuse diuresis - non-stop loss of fluid by the body.
In terms of preventing or treating cerebral complications of hypoglycemic coma, drugs such as Piracetam or Nootropil are well suited. These drugs are typical representatives of so-called nootropics - a means of improving cerebral circulation. They are also used in the elderly and in patients who have suffered acute cerebrovascular accident. To prevent an acute increase in blood pressure in the vessels of the brain, a magnesium sulfate solution, better known as Magnesia, is used. Enter usually up to 10 ml (depending on body weight) in a concentration not exceeding 25%.
The introduction of glucose solution should be carried out under laboratory control of its level in the blood. When the glucose concentration reaches 14 - 16 mmol per liter, you should begin to inject the ultrashort insulin subcutaneously in a dosage of up to 6 units every 3 to 5 hours.
Emergency care for hypoglycemic coma
The clinic of hypoglycemic coma is a direct evidence that the condition is extremely dangerous for human life. Complications of hypoglycemic coma with untimely initiated or improperly administered therapy can significantly reduce a person's quality of life, leading to disability or various kinds of decompensation. Of the acute complications of hypoglycemic coma, cerebral edema or cerebral hemorrhage due to hypertension may occur.
Therefore, it is important to be guided by the rules of phasing in the provision of emergency care for hypoglycemic coma.
To begin with, the victim is given 1 ml of glucagon, which stimulates the production of glucose from glycogen in the liver. If the administration did not produce the expected result, this may indicate depletion of endogenous glycogen stores or about alcohol use the day before. Next, enter the hypertonic (40%) glucose solution intravenously, struino, once to 110 ml (depending on the body weight and the body's response to the administration). This should contribute to the normalization of blood glucose, and under ideal conditions - the release of a person from the coma immediately at the end of the infusion. If, after the introduction of the hypertonic solution, there remains a pronounced clinic of hypoglycemic coma, you should proceed to the dropwise injection of a glucose solution of a lower concentration in a volume of 250-300 ml.
In order to prevent brain edema, a person needs to inject intravenously drip osmotic diuretics (Mannitol and Manitol). And after - the so-called emergency diuretics (Furosemide or Lasix). It is necessary before the infusion therapy to establish at least two catheters - for intravenous administration of drugs and the bladder, as diuretics will be used. With care, you need to introduce short-acting insulin, when the level of glycemia reaches 13 - 17 millimoles per liter of blood, to reduce to normal, without provoking a new attack of hypoglycemic coma.
There is also a non-pharmacological method of providing emergency care for hypoglycemic coma. These are strong tweaks and bumps in the area of the greatest muscle mass. This is argued by the fact that with physical exposure, a large amount of adrenaline and other catecholamines are released into the blood, stimulating an emergency synthesis of glucose in the liver. But, again, this method does not help with the depletion of glycogen stores.
During intensive care, it is necessary to examine the on-duty neurologist-resuscitator and cardiologist to fix and evaluate the electrocardiogram and the electroencephalogram. These measures will assess the severity of hypoglycemic coma, and also predict possible complications of hypoglycemic coma.
After leaving the coma, the patient should be carefully monitored to avoid relapse. The attending physician-endocrinologist should reconsider the tactics of treatment and conduct a complete examination of the patient, which should include both laboratory and instrumental methods of examination during the day for one or two weeks.
In addition, diet correction is important. It should be based on the individual schedule of the day, the features of the working schedule and daily fluctuations in glycemia. To prevent attacks of hypoglycemia, fractional frequent meals are necessary with the use of a small amount of quick-worted high-carbohydrate food. Insulin therapy also needs to be adjusted to the daily routine. If possible, it should be a ballous - complement the deficiency of insulin produced during meals (ultrashort action). This introduction of insulin prevents the possible consequences of stressful situations and physical exertion, which often occur with the application of insulin prolonged action.
The intake of food must strictly correspond to the necessary energy. Often, such distribution is used so that about a quarter of all accepted food is for breakfast and dinner, about 15% for lunch, and the rest should remain for intermediate "snacks".
Thus, an important role in the prevention of clinical manifestations of hypoglycemia and the development of hypoglycemic coma belongs to prevention. All prescriptions of the doctor to a patient with a diagnosis of diabetes mellitus are mandatory. It is on the patient's self-control that the state of his carbohydrate metabolism, and hence the whole organism, depends. Proper nutrition, well-organized daily routine, a schedule of food and medicine will help a person achieve a lasting improvement in well-being, and thus, quality of life.
The very same treatment of hypoglycemic coma includes relief of symptoms and prevention of consequences.
Emergency care for hypoglycemic coma means an emergency replacement of the amount of glucose in the blood. It is also important to prevent negative complications from the central nervous and cardiovascular systems. These measures include measures to prevent cerebral edema, malignant intracranial hypertension, which are realized by the introduction of diuretic drugs. At the last stage of treatment of hypoglycemic coma, a person should receive rehydration and detoxification therapy. This is necessary to remove possible derivatives of acetone from the blood and normalize the liquid balance.
When discharging from a hospital after hypoglycemic coma, the patient should undergo a special examination for doctors to detect any undetected or mild complications early.