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| ==Overview== | | ==[[Diabetic coma overview|Overview]]== |
| '''Diabetic coma''' is a [[medical emergency]] in which a person with [[diabetes mellitus]] is [[coma]]tose (unconscious) because of one of the [[diabetes mellitus#complications|acute complications]] of diabetes:
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| #Severe [[diabetic hypoglycemia]]
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| #[[Diabetic ketoacidosis]] advanced enough to result in unconsciousness from a combination of severe [[hyperglycemia]], [[dehydration]] and [[Shock (medical)|shock]], and exhaustion
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| #[[Hyperosmolar nonketotic coma]] in which extreme [[hyperglycemia]] and [[dehydration]] alone are sufficient to cause unconsciousness.
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| 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. [[Paramedic]]s 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 [[diagnosis|diagnostic process]] used to distinguish among them, as well as a few other conditions which must be considered.
| | ==[[Diabetic coma historical perspective|Historical Perspective]]== |
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| ==Severe hypoglycemia== | | ==[[Diabetic coma classification|Classification]]== |
| People with [[type 1 diabetes mellitus]] who must take [[insulin]] in full replacement doses are most vulnerable to episodes of [[diabetic hypoglycemia|hypoglycemia]]. It is usually mild enough to reverse by eating or drinking [[carbohydrate]]s, 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 [[alcohol|drinking]]. Some people with diabetes can lose their ability to recognize the symptoms of early hypoglycemia.
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| 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 [[convulsion]]s 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 [[glucose meter|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.
| | ==[[Diabetic coma pathophysiology|Pathophysiology]]== |
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| Unconsciousness due to hypoglycemia is treated by raising the blood glucose with intravenous glucose or injected [[glucagon]].
| | ==[[Diabetic coma causes|Causes]]== |
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| ==Advanced diabetic ketoacidosis== | | ==[[Diabetic coma differential diagnosis|Differentiating Diabetic coma from Other Diseases]]== |
| [[Diabetic ketoacidosis]] (DKA), if it progresses and worsens without treatment, can eventually cause unconsciousness, from a combination of severe [[hyperglycemia]], [[dehydration]] and [[Shock (medical)|shock]], and exhaustion. Coma only occurs at an advanced stage, usually after 36 hours or more of worsening [[vomiting]] and [[hyperventilation]]. | |
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| 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.
| | ==[[Diabetic coma epidemiology and demographics|Epidemiology and Demographics]]== |
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| 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]].
| | ==[[Diabetic coma risk factors|Risk Factors]]== |
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| Treatment of DKA consists of isotonic fluids to rapidly stabilize the circulation, continued intravenous [[saline (medicine)|saline]] with [[potassium]] and other electrolytes to replace deficits, insulin to reverse the ketoacidosis, and careful monitoring for complications.
| | ==[[Diabetic coma screening|Screening]]== |
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| ==Nonketotic hyperosmolar coma== | | ==[[Diabetic coma natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| [[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 diabetes|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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| The diagnosis is usually discovered when a chemistry screen performed because of obtundation reveals extreme hyperglycemia (often above 1800 mg/dl (100 mM)) and dehydration. The treatment consists of insulin and gradual rehydration with intravenous fluids.
| | ==Diagnosis== |
| | [[Diabetic coma history and symptoms|History and Symptoms]] | [[Diabetic coma physical examination|Physical Examination]] | [[Diabetic coma laboratory findings|Laboratory Findings]] | [[Diabetic coma electrocardiogram|Electrocardiogram]] | [[Diabetic coma chest x ray|Chest X Ray]] | [[Diabetic coma CT|CT]] | [[Diabetic coma MRI|MRI]] | [[Diabetic coma echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Diabetic coma other imaging findings|Other Imaging Findings]] | [[Diabetic coma other diagnostic studies|Other Diagnostic Studies]] |
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| ==Identifying the cause of diabetic coma== | | ==Treatment== |
| Diabetic coma was a more significant diagnostic problem before the late 1970s, when glucose meters and rapid blood chemistry analyzers became universally available in hospitals. In modern medical practice, it rarely takes more than a few questions, a quick look, and a glucose meter to determine the cause of unconsciousness in a patient with diabetes. Laboratory confirmation can usually be obtained in half an hour or less. Also, the astute physician remembers that other conditions can cause unconsciousness in a person with diabetes: stroke, uremic encephalopathy, alcohol, drug overdose, head injury, or seizure. | | [[Diabetic coma medical therapy|Medical Therapy]] | [[Diabetic coma surgery|Surgery]] | [[Diabetic coma primary prevention|Primary Prevention]] | [[Diabetic coma secondary prevention|Secondary Prevention]] | [[Diabetic coma cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Diabetic coma future or investigational therapies|Future or Investigational Therapies]] |
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| Fortunately, most episodes of diabetic hypoglycemia, DKA, and extreme hyperosmolarity do not reach unconsciousness before a family member or caretaker seeks medical help.
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| == See also == | | == See also == |