DIABETIC COMA_Clinical features and Management

Posted by e-Medical PPT Sunday, September 2, 2012
Hypoglycemia or low blood glucose is a clinical state associated with < 50mg/dl or low plasma glucose with typical symptoms.
Whipples triad =
 venous plasma glucose <50mg/dl.
 Classical symptoms.
 Relief of symptoms with glucose.

DCCT Definition
Event resulting in seizure,coma ,confusion or symptoms like sweating,palpitation,hunger with finger stick glucose < 50 mg/dl and amelioration of symptom by elevation of blood glucose.
Prodromal symptoms occuring before the event are well remembered.
Severe hypoglycemic symptoms requiring hospital admission and treatment with IV glucose or glucagon.

Mechanisms for fasting hypoglycemia
Under production
   Hormone deficiencies
   Enzyme defects
   Substrate deficiency
   Chronic infections
Over utilization 
      Hyper insulinism
      exogeneous insulin overdose.
      Auto immunity

Risk factors for severe hypoglycemia
Intensive insulin therapy & tight glycemic control.
Hypoglycemia unawareness –acute & chronic.
Long duration of diabetes.
Increasing age.
Excessive alcohol.
Renal failure/ Hepatic failure
Hypothyroidism/ Hypopituitarism/ Hypoadrenalism

Hypoglycemia in non diabetic scenario
Zollinger-Ellison syndrome -Whipple’s triad, diarrhea ,muscle wasting,tiredness. May be associated with neurofibroma. 5 hour OGGT shows < 50mg/dl. Serum insulin level-20micro units /ml, increased proinsulin level.
Hereditary fructose intolerance – enlarged liver,jaundice,cirrhosis,albuminurIa, aminoaciduria,mental retardation. Ingestion of fruit leading to vomiting and hypoglycemia

Grading of Hypoglycaemia
Grade 1 or mild : patient can recognize hypo and able to self treat
Grade 2 or moderate : severe hypo prevents patient from self treating but with assistance oral treatment is possible.
Grade 3 or severe : severe degree of neuroglycopenia  requiring parenteral glucagon/dextrose.

Nocturnal Hypoglycemia
Is common (biochem hypos occur frequently).
Asymptomatic/morning headache/hangover.
Often identified by partner: sweating, fretting.
May lead to sudden death.
Unsatisfactory time action profile of certain insulins; physio defences against hypo reduced in flat position; sympathetic responses to hypo reduced in slow wave sleep
Dawn phenomenon vs Somogyi effect
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