Diabetic coma

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Diabetic coma is a medical emergency in which a person with diabetes mellitus is comatose (unconscious) because of one of the acute complications of diabetes. Severe diabetic hypoglycemia, diabetic ketoacidosis or Hyperosmolar nonketotic coma in which extreme hyperglycemia and dehydration alone are sufficient to cause unconsciousness, are the complications of diabetes.

In most medical contexts, the term diabetic coma refers to the diagnostic dilemma posed when a physician is confronted with an unconscious patient about whom nothing is known except that he has diabetes. An example might be a physician working in an emergency department who receives an unconscious patient wearing a medical identification tag saying DIABETIC. Paramedics may be called to rescue an unconscious person by friends who identify him as diabetic. Brief descriptions of the three major conditions are followed by a discussion of the diagnostic process used to distinguish among them, as well as a few other conditions which must be considered.

Dabetic coma can be classified as coma due to Severe diabetic hypoglycemia, diabetic ketoacidosis or Hyperosmolar nonketotic coma.

Anyone who has diabetes is at risk of a diabetic coma.

Left untreated, a diabetic coma can be fatal. Prognosis of diabetic coma depends on whether the patient is treated promptly and properly.

Tests, including blood sugar level, ketone level in blood and urine, blood level of nitrogen or creatinine and potassium in your blood, may be helpful for the diagnosis of the cause.

The treatment of diabetic coma consists of insulin and gradual rehydration with intravenous fluids. Treatment of DKA consists of isotonic fluids to rapidly stabilize the circulation, continued intravenous saline with potassium and other electrolytes to replace deficits, insulin to reverse the ketoacidosis, and careful monitoring for complications.

Controlling diabetes and recognizing the early signs of dehydration and infection can help prevent this condition.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Dabetic coma can be classified as coma due to Severe diabetic hypoglycemia, diabetic ketoacidosis or Hyperosmolar nonketotic coma.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

People with type 1 diabetes mellitus who must take insulin in full replacement doses are most vulnerable to episodes of hypoglycemia. It is usually mild enough to reverse by eating or drinking carbohydrates, but blood glucose occasionally can fall fast enough and low enough to produce unconsciousness before hypoglycemia can be recognized and reversed. Hypoglycemia can be severe enough to cause unconsciousness during sleep. Predisposing factors can include eating less than usual, prolonged exercise earlier in the day, and heavy drinking. Some people with diabetes can lose their ability to recognize the symptoms of early hypoglycemia.

Unconsciousness due to hypoglycemia can occur within 20 minutes to an hour after early symptoms and is not usually preceded by other illness or symptoms. Twitching or convulsions may occur. A person unconscious from hypoglycemia is usually pale, has a rapid heart beat, and is soaked in sweat: all signs of the adrenaline response to hypoglycemia. The individual is not usually dehydrated and breathing is normal or shallow. A meter or laboratory glucose at the time of discovery is usually low, but not always severely, and in some cases may have already risen from the nadir that triggered the unconsciousness. Unconsciousness due to hypoglycemia is treated by raising the blood glucose with intravenous glucose or injected glucagon.

Diabetic ketoacidosis (DKA), if it progresses and worsens without treatment, can eventually cause unconsciousness, from a combination of severe hyperglycemia, dehydration and shock, and exhaustion. Coma only occurs at an advanced stage, usually after 36 hours or more of worsening vomiting and hyperventilation.

In the early to middle stages of ketoacidosis, patients are typically flushed and breathing rapidly and deeply, but visible dehydration, pallor from diminished perfusion, shallower breathing, and rapid heart rate are often present when coma is reached. However these features are variable and not always as described.

If the patient is known to have diabetes, the diagnosis of DKA is usually suspected from the appearance and a history of 1-2 days of vomiting. The diagnosis is confirmed when the usual blood chemistries in the emergency department reveal hyperglycemia and severe metabolic acidosis.

Nonketotic hyperosmolar coma usually develops more insidiously than DKA because the principal symptom is lethargy progressing to obtundation, rather than vomiting and an obvious illness. Extreme hyperglycemia is accompanied by dehydration due to inadequate fluid intake. Coma from NKHC occurs most often in patients who develop type 2 or steroid diabetes and have an impaired ability to recognize thirst and drink. It is classically a nursing home condition but can occur in all ages.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Anyone who has diabetes is at risk of a diabetic coma.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Left untreated, a diabetic coma can be fatal. Prognosis of diabetic coma depends on whether the patient is treated promptly and properly.

Complications related to nonketotic hyperosmolar coma

• Acute circulatory collapse (shock)
• Blood clot formation
• Brain swelling (cerebral edema)
• Increased blood acid levels (lactic acidosis)

People with diabetic ketoacidosis need close and frequent monitoring for complications. Surprisingly, the most common complications of DKA are related to the treatment:

• Hypokalemia and often, potassium depletion
• Cerebral edema ^[1]
• Hyperglycemia
• Ketoacidemia
• Fluid and electrolyte depletion ^[2]
• Aspiration
• Unrecognized renal tubular necrosis
• Pulmonary edema ^[3]

Patients who develop this syndrome are often already ill. The death rate with this condition is as high as 40%.

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