SEVERE HYPOGLYCEMIA DKA/HHS STROKE

1. APPROACH TO A CASE OF COMA
IN A DIABETIC PATIENT
Dr. Md SHAHID IQUBAL
1st Year P.G Student,
Deptt Of Medicine, Nmch

2. A Case Study on coma in a diabetic patient
• A 60 year old lady with history of type 2 diabetes for
10 years and non hypertensive presented to the nmch
emergency department with loss of consciousness and
profuse sweating.
• She had also same type of complain 1 month back.
• She was on glimepride 2mg and metformin 1000 mg
daily since diagnosis.
• On the day of the admission she had taken her
diabetes medications at home,after that she did not
take food due to loss of appetite. After some hour she
was found unconscious and came to nmch patna.

3. Examination-
• Patient was unconscious
• Pulse 90 beats/minute, high volume
• BP 140/90mmHg
• Respiration 16 breaths/minute, normal breathing
• Tongue moist, skin clammy and sweating
• Plantar –extensor of both toe
• Deep tendon Reflexes - brisk
• Chest- clear,
• Heart sounds normal.
• abdomen- soft,no hepatosplenomegaly,no guarding,no
rigidity

4. • Blood sample was taken and sent for
laboratory examination for
CBC,RBS,ELECTROLYTES,B.UREA,S.CREATININE
• Plan for ct brain
• ABG
• ECG

5. COMA IN DIABETES
• COMA-defined as a deep sleeplike state from
which the patient cannot be aroused.
• If a diabetic patient comes to emergency in
state of coma then following possibilities may
be considered–
1. Severe hypoglycemia
2. HHS/DKA
3. Stroke

6. Other causes of coma are as follows-
(Not directly related to diabetes)
 Traumatic brain injuries.
• Infections.
Encephalitis and meningitis. Septicemia.
 Uremia
• Seizures. Status epilepticus, post ictal coma,
• Tumors of the brain,
Sudden bleeding inside the tumor causing acute swelling,
massive brain edema as seen in high malignant tumors,
• Alcohol –
Acute alcoholic intoxication results in coma.

7. General approach to a case of coma in
diabetic patient
 SEVERE HYPOGLYCEMIA-
 in this case positive history
 -h/o-OHA –SU or insulin
 Missed meal after medication
 h/o-sweating ,palpitation,confusion,loss of consciousness
 On examination-
pulse –tachycardia ,high volume
b.p-high
 Respiration –normal rate,pattern –normal,shallow
 CNS- plantar-b/l extensor ,DTR-brisk
 Blood sugar <50mg/dl

8. DKA/HHS
history that favours DKA/HHS
• History of irregular treatment ,
• h/o-nausea,vomiting,abdominal pain
• h/o increased thirst,and increased urination
• On examination-pulse rate increased,high volume
pulse
• B.p-decreased
• Skin-dry ,tongue-dry
• Respiration-rapid and deep(Kussmaul breathing)
• Acetone smell may be present on breath
• CNS-plantar-flexor type ,reflexes-diminished

9. DKA/HHS contd…….
• Investigation-
• Blood sugar >250mg/dl in DKA and >600mg/dl in
HHS
• Sodium –decreased
• Plasma ketones- ++++in DKA it may not be
positive in HHS
• ABG-arterial PH >7.3 in HHS and 6.8-7.3 in DKA
• Bicarbonate-<15meq/l
• Anion gap- increased in DKA ,may be normal in
HHS

10.  STROKE-
history that favours stroke-
sudden onset of loss of consciousness.prior to this may be h/o-
slurring of speech ,weakness of one side of body.
On examination-
• Pulse rate –normal or decreased
• B.p-normal or high
• Plantar-u/l extensor DTR-brisk of one side
• Pupil-may be unequal size
• Weakness of one side of body
• Investigation-
• Blood sugar –normal
• Dyslepidemia
• Ecg-AF,ST changes
• NCCT BRAIN-hyperdense ,hypodense area may be found
(Haemorrhagic ,or ischemic stroke)

11.  Laboratory results
• CBC- WBC 5890,Hg-6.8g/dl,
• RBS-34mg/dl
• Urea-71.2 ,Creatinine-4.29mg/dl
• Cholesterol-130.6mg/dl
• Tg-153.6,HDL-37.6,LDL-104.3
• Na-139meq/l,k-5.3 meq/l
• R/E urine-albumen++ ,sugar-nil
• CT brain-normal
On the basis of above
history,cilinical finding and results this is a case of
SU induced hypoglycemia

12. IMMEDIATE TREATMENT-
• 25 gram glucose (50 ml of 50%dextrose) IV
bolus given followed by dextrose infusion
• Within 10 minutes patient regains
consciousness
• After that patient is advised to take oral food
glucose containing fluids, as,Hypoglycemia
caused by a sulfonylurea can persist for hours
or even days.

13. DISCUSSION-
• This case was of hypoglycemia that is
documented by Whipple’s triad:
(1) symptoms consistent with hypoglycemia,
(2) a low plasma glucose concentration
measured with a precise method (not a glucose
monitor),and
(3) relief of symptoms after the plasma glucose
level is raised.

14. Risk factors of hypoglycemia
(1) insulin (or insulin secretagogue) doses are excessive, ill-timed, or
of the wrong type;
(2) the influx of exogenous glucose is reduced (e.g., during an
overnight fast or after missed meals or snacks);
(3)insulin clearance is reduced (e.g., in renal failure).
(4) insulin-independent glucose utilization is increased (e.g., during
exercise);
(5) sensitivity to insulin is increased(e.g.in the middle of the night, late
after exercise, or with increased fitness or weight loss);
(6) Endogenous glucose production is reduced (e.g., after alcohol
ingestion);

15. TAKE HOME MESSAGE
• Coma in diabetic patient is medical emergency
• Severe hypoglycemia,HHS are main causes of
coma in diabetic patient.
• By explaining the warning symptoms of
hypoglycemia caused by sulfonylurea or
insulin ,this can be prevented.
• By history and physical examination we can
differentiate between hypoglycemic and
hyperglycemic coma.

16. THANK YOU!