Hyperglycemia emergency care. How to provide first aid when symptoms of hyperglycemic coma appear. Pay special attention to your illness

Hyperglycemic coma - severe complication diabetes mellitus Develops with poor nutrition, infection, mental trauma, intoxication, and if the patient did not receive insulin or received insufficient insulin, or suddenly interrupted insulin treatment or sulfa drugs, lowering blood sugar.

Coma can occur as a result of hypoinsulinism with Graves' disease, acromegaly, Itsenko-Cushing's disease, bronze diabetes, pancreatitis, diencephalitis, etc. Great importance in development diabetic ketoacidosis has increased secretion of contrainsular hormones (glucagon, cortisol, etc.)

The normal level of glucose in blood plasma is less than 6.38 mmol/l, in whole venous blood and in whole capillary blood - less than 5.55 mmol/l. A hypoglycemic state develops when the concentration of glucose in the blood plasma decreases to 2.75 mmol/l. When the level of glucose in the blood increases above 8.88 mmol/l, sugar appears in the urine (glucosuria). Hyperglycemic coma appears against the background of high glycemia, reaching 14-33 mmol/l.

Harbingers

Sugar, acetone and acetoacetic acid appear in the urine, and hyaline casts and leached red blood cells appear in the sediment. Albuminuria.

Symptoms

Breathing is heavy, deep, noisy (Kussmaul). Smell of acetone from the mouth. The tongue is dry, slightly coated. Hypotony of the eyeballs.

The pulse is small, frequent, weak filling. Blood pressure is reduced. Sometimes a collapsed state.

Muscle flaccidity, often decreased or absent tendon reflexes. Body temperature is often reduced.

In the blood, neutrophilic leukocytosis with a shift in the formula to the left, severe hyperglycemia, sharp decline reserve alkalinity (acidosis) Hyperchloremia, hyponatremia. The hematocrit number and hemoglobin content are increased.

Differentiate with hypoglycemic coma, as well as with variations of diabetic coma: hyperglycemic (ketoacidotic), hyperosmolar (non-acidotic) and lactic acid (hyperlactic acidic) In contrast to the hyperglycemic coma described above, hyperosmolar coma is characterized by significant hyperglycemia, reaching 33-100 mmol/l, and the absence of ketonemia , hyperosmolarity of blood plasma (350-500 mOsm/l), hypernatremia (up to 170-200 mmol/l), hypokalemia and azotemia. This type of coma usually develops in the elderly, after excessive fluid loss.

Lactic acid coma often develops in the elderly. The anamnesis contains indications of long-term treatment diabetes mellitus with biguanide drugs. Glycemia is moderately elevated, there is no glucosuria. There is hyperkalemia, azotemia, high level lactic acid in the blood (more than 1.5 mmol/l), hyperpyruvatemia (more than 0.15 mmol/l)

Urgent Care

If the unconscious state continues and blood sugar has not decreased, then 20-30 units of insulin should be administered subcutaneously every 2 hours.

Required constant control for blood sugar, acetone and urine sugar.

When the blood glucose level decreases to 16.55 mmol/l, the insulin dose is reduced; At the same time, intravenous drip administration of a 5% glucose solution is started.

2. Isotonic sodium chloride solution - 800-1000 ml in a “cocktail” with 20-30 ml of 10% potassium chloride solution and 500 ml of 10% glucose solution - intravenously, drip.

In case of hyperosmolar coma, instead of isotonic, a hypotonic (0.45 - 0.6%) sodium chloride solution is used.

3. Sodium bicarbonate - 200-300 ml of 4% solution intravenously, drip.

4. Korglykon - 1 ml of 0.06% solution or strophanthin - 0.5 ml of 0.05% solution in 20 ml of isotonic sodium chloride solution intravenously, slowly.

5. Mezaton - 1 ml of 1% solution intramuscularly (can be repeated after 3-4 hours)

6. Sulfocamphocaine - 2 ml of 10% solution subcutaneously.

7. Ascorbic acid- 2-3 ml of 5% solution intramuscularly. Cocarboxylase - 0.1 g (2 ampoules of dry powder, 0.05 g each, diluted in 4 ml of solvent) intramuscularly or intravenously, drip.

8. In case of lactic acid coma, if the above measures are ineffective, hemodialysis is performed.

9. Hospitalization is urgent.

V.F.Bogoyavlensky, I.F.Bogoyavlensky

Coma

Diabetes- This endocrine disease related to absolute insufficiency of insulin (type 1 diabetes mellitus, insulin-dependent) or relative(type 2 diabetes mellitus non-insulin dependent).

Diabetic coma- one of the most severe complications of diabetes mellitus, resulting from absolute or relative deficiency of insulin and metabolic disorders. There are two types of diabetic coma: hypo- and hyperglycemic.

Hypoglycemic coma develops with a sharp decrease in blood glucose levels to 2-1 mmol/l. Occurs due to a violation of the diet, an overdose of insulin, or the presence of a hormonal tumor (insulinoma).

Clinical picture hypoglycemic coma is characterized by loss of consciousness, psychomotor and motor impairment, hallucinations, clonic and tonic convulsions. The skin and mucous membranes are sharply pale, moist, it is noted profuse sweat, tachycardia with relatively normal blood pressure numbers, rapid, shallow, rhythmic breathing. Blood glucose levels decrease

Intensive therapy : 20-80 ml of 40% glucose solution is immediately injected intravenously. If it is possible to control blood glucose levels, maintain it within 8-10 mmol/l by administering a 10% glucose solution with insulin.

According to indications, glucagon, adrenaline, hydrocortisone, cocarboxylase, and ascorbic acid are used.

For the prevention and treatment of cerebral edema, mechanical ventilation is performed in hyperventilation mode, intravenous infusions of 20% mannitol.

Ghyperglycemic coma. Blood glucose concentrations sometimes reach

55 mmol/l.

Clinical picture hyperglycemic coma is characterized by a lack of consciousness, skin and mucous membranes are dry, warm, moderately pale or hyperemic. It is often felt acetone smell from mouth. Eyeballs sunken, “soft”, pulse increased, blood pressure decreased. Bradypnea, respiratory rhythm disturbances (Kussmaul type), polyuria, agitation, convulsions, and increased reflex activity are noted.

Intensive therapy. Correction of hyperglycemia is carried out by administering insulin. Insulin is preferred short acting as more “manageable”. The most effective is intravenous drip administration using dispensers at a rate of 6-10 units per hour under constant monitoring of blood glucose concentration. Depending on the level of hyperglycemia, the first dose can be increased to 20 units. Correction of metabolic acidosis should be aimed at activating buffer systems and normalizing the functions of the cardiovascular and respiratory systems, blood oxygenation, improvement of microcirculation and perfusion of organs and tissues.

What is hyperglycemic (diabetic) coma

Hyperglycemic (diabetic) coma- a relatively slowly developing condition associated with an increase in blood glucose levels in diabetes mellitus and the accumulation of toxic metabolic products

What provokes hyperglycemic (diabetic) coma:

Uncontrolled treatment of diabetes mellitus with insufficient insulin administration.

Refusal to use insulin.

At the onset of diabetes mellitus, when the patient still does not know about his disease at all, before a diagnosis is made, as a rule, diabetic (hyperglycemic) coma begins to develop.

Various dietary errors, injuries and infectious diseases can provoke the development of diabetic (hyperglycemic) coma in patients with diabetes.

Occurs when diabetes mellitus lasts for a long time minor symptoms and the patient does not receive insulin or receives small doses.

Symptoms of hyperglycemic (diabetic) coma:

Precomatose and coma patients with diabetes require their emergency hospitalization. Comprehensive treatment of coma includes restoring insulin deficiency, combating dehydration, acidosis, and loss of electrolytes. In the initial stage of a diabetic coma, insulin must first be administered. Only crystalline (simple) insulin is administered and in no case long-acting drugs. Insulin dosage calculated depending on the depth of the coma. At mild degree coma, 100 units are administered, for severe coma - 120-160 units and for deep coma - 200 units of insulin. Due to impaired peripheral circulation with the development of cardiovascular failure during the period of diabetic coma, the absorption of administered drugs from subcutaneous tissue slows down, therefore half of the first dose of insulin should be administered intravenously in 20 ml of isotonic sodium chloride solution.

For elderly patients, it is advisable to administer no more than 50-100 units of insulin due to the risk of developing coronary insufficiency. In precoma, half the full dose of insulin is administered.

Subsequently, insulin is administered every 2 hours. The dose is selected depending on the blood glucose level. If after 2 hours the blood glucose level increases, then the dose of administered insulin is doubled. The total amount of insulin administered during diabetic coma, ranges from 400 to 1000 units per day. Along with insulin, glucose should be administered, which has an anti-ketogenic effect. It is recommended to start administering glucose after its level in the blood begins to fall under the influence of insulin. A 5% glucose solution is administered intravenously. To restore lost fluid and electrolytes, 1-2 liters per hour of an isotonic sodium chloride solution is injected intravenously in combination with 15-20 ml of a 10% potassium chloride solution, warmed to body temperature. In total, 5-6 liters of liquid are administered per day; for patients over 60 years of age, as well as in the presence of cardiovascular insufficiency - no more than 2-3 liters. To combat metabolic acidosis, 200-400 ml of a 4-8% solution of freshly prepared sodium bicarbonate is administered intravenously, which cannot be mixed with other solutions. Intravenous administration of 100-200 mg of cocarboxylase, 3-5 ml of 5% ascorbic acid solution is indicated. To restore hemodynamic disorders, cardiac glycosides are prescribed (1 ml of 0.06% solution of corglycone intravenously), 1-2 ml of a 20% solution of caffeine or 2 ml of cordiamine are injected subcutaneously or intravenously.

Hyperglycemic hyperketonemic coma

A serious complication of diabetes mellitus, which is a consequence of severe insulin deficiency and decreased tissue glucose utilization, which leads to severe ketoacidosis, disruption of all types of metabolism, dysfunction of all organs and systems, primarily the nervous system, and loss of consciousness.

Emergency care algorithm :

Urgently call a doctor to provide qualified medical care;

Ensure monitoring of the patient’s condition (blood pressure, pulse, respiratory rate);

Take blood and urine from the patient for testing;

Prepare emergency medications when the doctor arrives:

for intravenous drip administration - Ringer solution, 4% sodium bicarbonate solution, 5% glucose solution, 0,9% chloride solution sodium;

short-acting insulin preparations (Homorap, Actrapid, Insulrap, Humalog);

cardiac glycosides: 0.05% strophanthin solution or 0.06% corglycone solution, 10% solution of caffeine, 1% mesatone solution;

cocarboxylase, ascorbic acid;

warm 2% solution of soda for enema;

5. Provide introduction medicines as prescribed by a doctor

Hypoglycemic coma.

Arises as a result sharp decline blood sugar levels (hypoglycemia), most often in patients diabetes mellitus receiving insulin. The pathogenesis of hypoglycemia is based on the discrepancy between insulinemia and glycemic levels. In typical cases, hypoglycemia occurs due to an overdose of insulin, significant physical activity or insufficient food intake after its administration and develops 1 to 2 hours after the insulin injection (sometimes later). When administering long-acting insulin preparations, a hypoglycemic state and coma can develop after 4-5 hours, but also with insufficient food intake that does not correspond to the administered dose of the drug.

Algorithm for providing emergency care:

Administer 10-20 ml intravenously. 40% glucose solution;

When blood pressure decreases, administer intravenously plasma and its substitutes: polyglucin, rheopolyglucin, albumin and cardiac glycosides: corglycon - 0.06% solution 0.5 mg/kg slowly intravenously, hormones, prednisolone, hydrocortisone 5 ml/kg;

At convulsions administer diazepam 0.3-0.5 ml/kg slowly intravenously or sodium hydroxybutyrate 20% solution 0.5-0.75 ml/kg.

Main signs of diabetic and hypoglycemic coma

Hyperglycemic coma is a complication of a “sweet disease” of an acute nature, accompanied by high blood sugar levels against the background of absolute (with type 1 disease) or relative (with type 2) insulin deficiency. The condition is considered critical and requires immediate hospitalization and specialist intervention. Anyone who suffers from diabetes or has sick friends or relatives should know the emergency care algorithm for hyperglycemic coma.

Differentiation of coma

Since there are three different types hyperglycemic coma, then the assistance provided at the medical stage differs for each of them:

• ketoacidotic coma;
• hyperosmolar coma;
• Lactic acidosis.

Ketoacidosis is characterized by the formation of ketone bodies (acetone) and develops against the background of insulin-dependent diabetes mellitus. A hyperosmolar state occurs in type 2 of the disease, ketone bodies are absent, but patients suffer from high performance sugar and significant dehydration.

Lactic acidosis is characterized by moderate glycemia in comparison with the first two pathologies, develops when non-insulin dependent diabetes and is characterized by the accumulation of a significant amount of lactic acid in the blood.

Clinic

The symptoms of ketoacidosis and hyperosmolar coma are similar. Clinical picture increases gradually. Excessive thirst appears copious discharge urine, attacks of nausea and vomiting, convulsions.

The difference that makes it possible to differentiate these two conditions is the presence of a specific odor of acetone coming from the mouth in ketoacidosis and its absence in the hyperosmolar state.

In addition, at home you can check your sugar level (with hyperosmolar coma it can reach 40 mmol/l or higher, with ketoacidosis - 15-20 mmol/l) and determine the presence of acetone bodies in the urine using express test strips.

Determining the level of acetone in urine is one of the criteria for differentiating the types of hyperglycemic coma

Lactic acidosis is not characterized by excessive thirst and polyuria, and there are no ketone bodies in the urine. It is almost impossible to diagnose at home.

First aid

For any type of hyperglycemic coma, you should immediately call emergency specialists and perform a series of sequential measures before their arrival. First aid is as follows:

• Place the patient in a horizontal position.
• Ensure receipt fresh air, unbutton or remove outer clothing. If necessary, remove the tie and belt.
• Turn the patient's head to the side so that in case of an attack of vomiting the person does not choke on the vomit.
• Control the position of the tongue. It is important that retraction does not occur.
• Determine whether the patient is on insulin therapy. If the answer is yes, create the necessary conditions so that he gives the injection himself or helps him administer the hormone in the required dosage.
• Control arterial pressure and pulse. If possible, record indicators in order to report them to ambulance specialists.
• If the patient is “cowardly,” warm him up by covering him with a blanket or providing him with a warm heating pad.
• Give enough drink.
• In case of cardiac or respiratory arrest, it is necessary to carry out resuscitation measures.

Features of resuscitation

Resuscitation must begin in adults and children, without waiting for the arrival of ambulance specialists, when symptoms appear: lack of pulse on carotid arteries, lack of breathing, the skin acquires a gray-bluish tint, the pupils are dilated and do not react to light.

1. Place the patient on the floor or other hard, flat surface.
2. Tear or cut outer clothing to provide access to the chest.
3. Tilt the patient's head back as far as possible, place one hand on the forehead and extend the other lower jaw patient forward. This technique ensures airway patency.
4. Make sure there is no foreign bodies in the mouth and throat, if necessary, remove mucus with a quick movement.

Compliance with the rules of resuscitation is a step towards its successful completion

Mouth-to-mouth breathing. A napkin, a piece of gauze or a handkerchief is placed on the patient’s lips. Done deep breath, lips are pressed tightly to the patient's mouth. Then they exhale forcefully (for 2-3 seconds), while closing the person’s nose. Efficiency artificial ventilation can be seen by the rise of the chest. The frequency of breaths is 16-18 times per minute.

Indirect cardiac massage. Place both hands on the lower third of the sternum (approximately in the center of the chest), standing on the left side of the person. Energetic pushes are performed towards the spine, shifting the surface of the chest by 3-5 cm in adults, 1.5-2 cm in children. The frequency of pressing is 50-60 times per minute.

When combining mouth-to-mouth breathing and cardiac massage, as well as carrying out activities by one person, it is necessary to alternate 1 breath with 4-5 presses on chest. Resuscitation is carried out until emergency personnel arrive or until the person shows signs of life.

Important! If the patient has regained consciousness, do not leave him alone under any circumstances.

Medical stage

After the specialists arrive, the patient’s condition is stabilized and he is subject to hospitalization in the department intensive care. Emergency care for hyperglycemic coma at the medical stage depends on the type of condition that has developed in a patient with diabetes.

Patient hospitalization – required condition, even if the condition normalizes at home

Ketoacidotic coma

A prerequisite is the administration of insulin. First, it is administered as a stream, then intravenously by drip with 5% glucose to prevent the occurrence of a hypoglycemic state. The patient's stomach is washed and the intestines are cleansed using a 4% bicarbonate solution. Intravenous administration of saline, Ringer's solution to restore fluid levels in the body, and sodium bicarbonate to restore lost electrolytes is indicated.

Important! Blood pressure and quantitative blood glucose levels are constantly monitored. The glycemic level is reduced gradually so that it is not critical for the patient.

To support the functioning of the heart and blood vessels, glycosides, Cocarboxylase are used, and oxygen therapy is performed (saturation of the body with oxygen).

Hyperosmolar state

Emergency care for this coma has certain differences:

• a significant amount of infusion drugs is used (up to 20 liters per day) to restore fluid levels in the body ( saline, Ringer's solution);
• Insulin is added to physiology and administered drip-wise so that the sugar level decreases slowly;
• when glucose levels reach 14 mmol/l, insulin is administered at 5% glucose;
• bicarbonates are not used because there is no acidosis.

Infusion therapy – important stage emergency medical care

Lactic acidosis

Features of relieving lactic acidotic coma are as follows:

• Methylene blue is injected dropwise into a vein, allowing it to bind hydrogen ions;
• administration of Trisamin;
• performing peritoneal dialysis or hemodialysis to cleanse the blood;
• intravenous drip of sodium bicarbonate;
• small doses of insulin infused with 5% glucose as preventive measure a sharp decrease in the quantitative indicators of glucose in the blood.

Awareness of how to properly provide first aid for a hyperglycemic state, as well as the ability to perform resuscitation measures, can save someone's life. Such knowledge is valuable not only for patients with diabetes, but also for their relatives and friends.