Diabetic shock Symptoms and treatment of diabetic shock

 Diabetic shock Symptoms and treatment of diabetic shock

Voice of symptoms and signs

Physical examination should pay attention to the degree of water loss, whether there is deep and rapid breathing, breath ketone smell and peripheral circulation failure.

1. The medical history is mostly the elderly, mostly in the age of 50 ~ 70, and the prevalence of men and women is roughly the same. About half of them are known to have diabetes, and about 30% have a history of heart disease. About 90% have kidney disease. Type of diabetes: type 2 diabetes. A few cases can be type 1 diabetes, mostly coexist with DKA. It can occur in patients with diabetes, such as cortisol and acromegaly.

2. Slow onset. During the first few days to several weeks before onset, the clinical symptoms of diabetes mellitus gradually aggravated, including polydipsia, polyuria, polyuria, fatigue, dizziness, lack of appetite and vomiting.

3. Patients with dehydration and peripheral circulation failure often have serious dehydration signs, such as dry skin, decreased elasticity, sunken eyeball, dry tongue and longitudinal cracks. When the patient has peripheral circulatory failure, the pulse is fast and weak, the jugular vein is incompletely filled in the lying position, upright hypotension, and the systolic pressure drop after standing is more than 1.3kpa (10mmhg) lower than that in the lying position. Many patients were in shock when seeing a doctor, but no cold sweat was found during physical examination due to serious dehydration. Although some patients have severe dehydration, the hypertonic state of plasma promotes the outflow of intracellular fluid and replenishes blood volume, which may mask the severity of water loss and maintain normal blood pressure.

4. About half of the patients with nervous system symptoms and signs have blurred consciousness, and 1 / 3 are in coma. Therefore, some patients are misdiagnosed as cerebrovascular accidents, and even mistakenly input hypertonic glucose solution or dehydrating agent, which aggravates the condition. The degree of consciousness disturbance in HNDC patients mainly depends on the degree and speed of plasma osmotic pressure rise, which is also related to the level of blood glucose, but not to the degree of acidosis. It has been found abroad that when the effective osmotic pressure of plasma exceeds 320mmol / L, mental symptoms can appear, such as indifference, drowsiness, etc; More than 350 mmol / L, 40% of patients may have blurred consciousness or coma. However, in some patients, the plasma effective osmotic pressure increased slowly. Although it had exceeded 400mmol / L at the time of treatment, the patients were still awake.

Nervous system signs: such as grand mal seizure, transient hemiplegia, muscle relaxation or involuntary contraction, aphasia, ipsilateral hemianopsia, visual impairment, nystagmus, hallucination, hemiparesthesia, positive Babinski sign and central fever. These signs suggest that the patient may be related to cortical or subcortical damage caused by dehydration, blood concentration or vascular embolism. Most of these changes can be reversed or returned to normal after effective treatment, and a few can still leave some symptoms of neurological and mental disorders within a period of time after HNDC correction.

5. Patients with accompanying symptoms and signs may have symptoms of hypertension, kidney disease, coronary heart disease and other original diseases; Pneumonia, urinary tract infection, pancreatitis and other induced manifestations; And cerebral edema, thrombosis, vascular embolism and other complications. The patient's body temperature is usually normal or slightly elevated. If the body temperature decreases, it may be accompanied by acidosis and / or sepsis, which should be paid enough attention.

Disease etiology speech

Pay attention to past diabetes history, recent treatment, whether there is acute infection, diarrhea, eating disorders, too much sugar. In the past, diabetes was not found, but excessive glucose consumption, severe mental stimulation, discontinued use, or a large reduction in insulin and a large dose of metformin hypoglycemic drugs were found.

1. Stress and infection, such as cerebrovascular accident, acute myocardial infarction, acute pancreatitis, gastrointestinal bleeding, trauma, surgery, heatstroke or hypothermia. Infection, especially upper respiratory tract infection and urinary tract infection, is the most common. 2. The elderly with insufficient water intake have decreased thirst center sensitivity, bedridden patients, patients with mental disorder or coma, and children who cannot take water actively.

3. Excessive water loss and dehydration, such as severe vomiting, diarrhea, large-area burn patients, neurological and surgical dehydration treatment, dialysis treatment, etc.

4. High sugar intake and input, such as large intake of sugary drinks and foods, intravenous input of a large amount of glucose solution when the diagnosis is unknown or missed, complete intravenous hypernutrition, and use of sugary solution for hemodialysis or peritoneal dialysis. Especially in patients with some endocrine diseases complicated with glucose metabolism disorders, such as hyperthyroidism, acromegaly, hypercortisolism, pheochromocytoma, etc.

5. Many drugs can become inducements, such as the massive use of glucocorticoids, thiazides or furosemide (furosemide) and other diuretics, propranolol, phenytoin sodium, chlorpromazine, cimetidine, glycerol, azathioprine and other immunosuppressants. Can cause or aggravate insulin resistance, increase blood glucose and aggravate dehydration. Some drugs such as thiazide diuretics can also inhibit insulin secretion and reduce insulin sensitivity, which can induce HNDC.

6. other factors such as acute and chronic renal failure, diabetic nephropathy and so on, because of the decline of glomerular filtration rate, the clearance of blood sugar also decreased. It can also be an incentive.

Diagnostic check voice

1. Immediately after admission, check blood glucose, ketone body, lactic acid, carbon dioxide binding force, urea nitrogen, blood pH, blood potassium, blood sodium, blood chlorine, plasma osmotic pressure (or calculate with the formula: 2 (Na + + K +) mmol / L + (glucose mg / D1 ÷ 18) + (urea nitrogen mg / D1 ÷ 2.8)), urine sugar and ketone body, and retest once every 1 ~ 4H until the blood biochemical test value returns to normal.

2. Renal function examination and ECG examination. Check urine routine and urine ketone body.

3. Classification

(1) blood sugar increased significantly, blood ketone increased, blood carbon dioxide binding power and pH value decreased. Ketone positive was diabetic ketoacidosis coma.

② Hyperosmotic nonketotic coma refers to those with extremely high blood glucose (nearly 1000mg / D1 or higher), high blood sodium, high plasma osmotic pressure and no obvious ketoacidosis; Common in elderly patients.

(3) because of shock or taking guanidine type hypoglycemic drugs, lactic acidosis in diabetic patients is caused by hyperglycemia, acidosis, general hyperglycemia and ketosis.

Treatment regimen voice

1. According to the coma nursing routine, measure the blood pressure once an hour

2. diabetic ketoacidosis coma treatment

(1) Injection of ordinary insulin

symptom

symptom

In order to prevent the adverse effects of brain edema and even death caused by too fast blood glucose decline and too fast correction of acidosis during treatment, the "low-dose insulin" treatment scheme can be applied: the first RI intravenous drip (in normal saline), the dose is calculated according to 5 ~ 10u / h (0.1U / kg? H), and intramuscular injection of 10 ~ 20u. Closely observe the blood glucose. When the blood glucose drops to 13.9mmol/l (250mg / D1), insulin is injected subcutaneously every 2h, and the dose is based on urine glucose + + + + 16U, + + + 12U, + + 8U, + 4U. If the blood glucose does not decrease after 2 ~ 3 hours of insulin and liquid treatment, there may be insulin resistance, and the hourly insulin dose should be doubled. In the treatment, we should avoid hypoglycemia caused by excessive insulin dosage and haste, or brain edema and hypokalemia caused by rapid decline of blood glucose.

(2) Correct water loss, electrolyte disorder and acidosis

① Supplement normal saline: 2000ml in the first 2 ~ 4h, about 4000ml in the first day. Fluid replacement should not be too fast or too much for the elderly and patients with cardiac and renal insufficiency. When the blood glucose drops below 13.9mmol/l (250mg / D1), use 5% glucose solution, or 4 / 5 parts of 5% glucose solution and 1 / 5 parts of normal saline. Encourage liquid and semi liquid food when the patient can eat.

② Timely potassium supplement: if the blood potassium is low or normal and the urine volume is sufficient, intravenous drip of potassium chloride 1 ~ 1.5g/500ml at the beginning of treatment, and potassium supplement of 6 ~ 9g on the first day. Those with hyperkalemia before treatment should pay attention to potassium supplementation 3 ~ 4h after treatment. Potassium supplement should be carried out under ECG monitoring, or blood potassium should be measured for 2 ~ 3H to prevent hyperkalemia. When the blood potassium is more than 5mmol / L, stop potassium supplement.

③ Correct acidosis: no alkali agent is used when the blood pH is > 7.15, 150ml of 5% sodium bicarbonate is used when the pH is < 7.0, and half amount is used when the pH is 7.0 ~ 7.15.

3. Treatment of hypertonic nonketotic coma

Diabetic coma

Diabetic coma

(1) Correct hypertonic water loss and electrolyte loss: immediately drip normal saline, use 2 ~ 3L within the first 2h, and then inject a considerable amount of warm boiled water from the gastric tube; If the blood volume recovers, the blood pressure rises to normal, but the osmotic pressure does not drop, especially when the blood sodium is high, 500 ~ 1500ml / D of hypotonic solution (0.45% or 0.6% sodium chloride) can be infused; When the blood glucose drops below 16.7mmol (300mg / D1), use 5% glucose solution for intravenous drip. When the blood potassium is less than 5mmol, potassium supplement shall be started to maintain the blood potassium at 4-5mmol / L.

(2) Insulin: the dosage should be smaller than that of ketoacidosis coma (4 ~ 6U / h). Generally, ordinary insulin can be used. Refer to the above "low dose" scheme and intravenous drip. However, early diagnosis and treatment are emphasized. Blood glucose should not be lower than 13.9mmol/l (250mg / D1) within 24 ~ 48h.

(3) Remove inducement treatment, and pay attention to monitoring life body disease, blood, urine sugar, electrolyte, bun, etc.

4. Treatment of lactic acidosis

(1) Actively anti shock, improve microcirculation perfusion and correct tissue hypoxia.

(2) Actively correct acidosis by intravenous drip of 1.5% or 5% sodium bicarbonate in a large amount. Generally, 200 ~ 1000ml of 5% sodium bicarbonate is used to improve the blood pH to normal within 8h, and 100mmol can be used within the first 24h. Be careful to avoid hypokalemia. Elderly patients with cardiac and renal insufficiency must use dialysis therapy. Aminobutanol (tham) can also be used, but sodium lactate is prohibited.

(3) Those with hyperglycemia were treated with RI; If there is no hyperglycemia, glucose must be added at the same time.

5. Stop using biguanides

6. In general treatment, the inducement should be controlled first

Those with infection should be controlled with antibiotics immediately. Those with shock should take active anti shock measures. If necessary, plasma or whole blood can be transfused. Norepinephrine should not be used.

Safety prompt voice

1. If the patient is still conscious and can swallow, the most effective way for hypoglycemic coma is to let the patient drink sweet water or eat candy and sweet cakes

2. The effective method for hyperglycemic coma is to drink salted tea or low salt tomato juice.

3. If the patient has lost consciousness, place the patient flat and untie the collar to ensure smooth airway.

Nursing measures voice

1. If a diabetic is in a coma, if it is not rescued in time, it is likely to be life-threatening. The nursing staff and family members must observe the patient's condition at any time.

2. Remember the amount of fluid in and out of the patient, such as the amount of drinking water or infusion, urine volume, etc;

3, when the patient is out of danger and regained consciousness, he should actively treat diabetes, adjust his diet and use insulin properly so as to make the body metabolize normal and avoid the recurrence of diabetic coma.

4, diabetes is a chronic disease requiring long-term treatment. Patients and their families need to dispel worries, build confidence and learn knowledge about diabetes, which is of great benefit to patients.

5, in case of prevention, diabetic patients should often carry cards with the words "diabetes" and other cards, and can also record some treatment methods and name and address of the patients, so that they can be referred to others and doctors when they suddenly lose consciousness.

First aid voice

1. First find out the cause of coma and distinguish between hyperglycemic coma and hypoglycemic coma.

diagnosis

diagnosis

2. when hypoglycemia occurs, the patient first feels dizzy, dizziness, starvation, trembling and cold sweating. Further development will appear irritability, convulsion, mental disorder, and finally fall into diabetic coma. If the patient can still swallow, for hypoglycemic coma, let the patient drink sugar water or eat sugar lumps, sweets, etc.

3. For hyperglycemic coma, let the patient drink some salt tea first and send it to the hospital for rescue at the same time.

4. if it is difficult to determine the cause of coma in diabetic patients, do not blindly take measures, because the treatment of coma caused by hyperglycemia and two hypoglycemia is completely the opposite.

5. If the patient has lost consciousness, place the patient flat, untie his collar, ensure smooth respiratory tract, and send him to the hospital for rescue immediately.

Four kinds of coma speech to prevent diabetes

In the process of diabetes treatment, there can be four kinds of acute and severe cases of diabetes ketoacidosis coma, non ketosis hyperosmolar diabetic coma, lactic acidosis coma and hypoglycemic coma of diabetes due to improper treatment or improper life regulation. If not rescued in time, there will be worries about life.

Diabetic ketoacidosis coma is due to severe insulin deficiency, so that lipolysis accelerated, fatty acids in the liver of the oxidation of ketone body increased significantly, resulting in ketone body accumulation, ketoacidosis. On this basis, a coma appeared, known as diabetic ketoacidosis coma. It is more commonly seen in diabetic patients who suddenly stopped insulin therapy and those who did not receive any treatment. Symptoms include polydipsia, polyuria, mental fatigue, fatigue, stupidity, nausea, deepening and accelerating breathing, then becoming shallow and slow. There may be rotten apple smell, dizziness, headache, even shock, drowsiness and coma in exhalation. The main treatment was rehydration, use of insulin, correction of electrolyte disorder and acid-base imbalance.

medication

medication

Non ketosis hyperosmolar diabetic coma is a disease characterized by severe hyperglycemia, hyperosmotic state, dehydration and coma in diabetics during severe infection, trauma, blood or peritoneal dialysis, using diuretics or corticosteroids. Symptoms include high fever and thirst, excessive drinking and urination, mental fatigue, nausea and stupidity, dry skin, decreased elasticity, cracked lips and tongue, sunken eyes, decreased blood pressure and other dehydration manifestations, even shock, shallow breathing, accelerated heart rate, dizziness, limb convulsions, trance, disorientation, irritability or indifference and even coma, epileptic seizures, hemiplegia, aphasia, hemianopia or nystagmus, Positive pathological reflex, etc. The main treatment is rapid and massive rehydration, use of insulin, maintenance of water electrolyte and acid-base balance, prevention and treatment of infection.

Diabetic lactic acidosis coma

Lactic acidosis in diabetic patients is commonly seen in patients with serious diseases of heart, lung, liver and kidney. Jiangtangling can increase the anaerobic fermentation of sugar and increase the production of lactic acid. Lactic acidosis will occur when the increased amount of lactic acid exceeds the uptake of liver and muscle and the excretion limit of kidney. Symptoms include nausea, vomiting, abdominal pain, abdominal distension, burnout, fatigue, deepening and accelerating breathing, and gradually falling into a coma. The treatment is mainly to discontinue Jiangtangling and other drugs that can cause lactic acidosis, use insulin and 5% sodium bicarbonate injection to control infection, correct dehydration and shock, diuresis and acid excretion, correct water electrolyte disorder, give oxygen, supplement potassium, and conduct blood or peritoneal dialysis with dialysate without lactate when necessary.

Diabetes hypoglycemia coma occurs in diabetes patients with excessive diet, excessive insulin injection, improper use of oral hypoglycemic agents, etc. Symptoms include hunger, fatigue, dizziness, headache, dripping cold sweat, palpitation, shortness of breath, tachycardia, nausea and vomiting, blurred vision, trembling all over the body, even insanity, abnormal behavior, drowsiness, coma, limb convulsions and even death. Hypoglycemia can occur during the day or at night. The onset of hypoglycemia in sleep at night can wake the patient from his dream, accompanied by cold sweat, irritability and tachycardia. In case of hypoglycemia, monitor blood glucose in time, feed sugar containing foods such as sugar water, candy, fruit, biscuits, snacks and steamed bread as soon as possible, and timely inject glucose and oxygen to the hospital, monitor blood glucose, blood pressure, heart rate, respiration and body temperature, observe mental changes, and give corresponding treatment to avoid accidents.

Main causes and first aid of diabetic coma

Nonketotic hyperosmolar coma

This kind of coma is most common in elderly diabetic patients over the age of 60. The main clinical manifestations were severe dehydration, hyperglycemia, high plasma osmotic pressure and neuropsychiatric symptoms.

Hypoglycemic coma

When the blood glucose is lower than 3 mmol / L, it is called hypoglycemia, and severe hypoglycemia will cause coma. The common reasons are: too much insulin or too much oral and hypoglycemic drugs and less food; The amount of exercise increased, but there was no corresponding increase in food intake.

ketoacidosis diabetic coma 

The reasons are:

1. diabetes patients withdrew or lost too much insulin or aggravated their condition.

2. Various acute and chronic infections.

3. Stress state, such as trauma, operation, delivery, pregnancy, acute myocardial infarction, hyperthyroidism, etc.

4. Eating disorders, eating too much or too little, drinking too much, etc.

Prognosis and Prevention

prognosis

preventive measure

preventive measure

To a large extent, the mortality rate of diabetic coma depends on the treatment of early diagnosis and complications. About 28% of the patients die mainly from hypertonic 48h after hospitalization, so the longer the duration of hyperosmolar, the higher the mortality. Various complications, especially infection, are the main cause of late death. However, as diabetes coma occurs mostly in the elderly, as Arieff points out, even if HNDC is diagnosed promptly and the treatment is positive, the mortality rate is still high. Therefore, it is important to try to prevent the onset of diabetic coma. All clinicians should be vigilant and avoid any factors that may cause diabetic coma in the treatment of elderly patients regardless of whether they have diabetes or not.

prevention

1. to strengthen the education and health examination of diabetes knowledge, early detection of early treatment, and elderly people over the age of 50 should regularly detect blood sugar. Patients diagnosed with diabetes should take regular medication, control diet, strengthen exercise, and strictly control blood sugar levels.

2. Control various inducing factors, actively treat various infections, pay attention to whether there is dehydration during hemodialysis, abdominal dialysis and mannitol dehydration, and timely monitor blood glucose and urine sugar.

3. Pay attention to inducing drug use, such as diuretics, glucocorticosterol, propranolol, etc.

Daily prevention

1. Pay attention to drinking water at ordinary times, and do not limit drinking water

2. Live regularly, live reasonably and pay attention to exercise

3. Elderly patients with minor diseases should be treated in time to prevent minor diseases

4. Strengthen blood glucose monitoring in case of any irregularity

Health tips voice

1. If the patient is still conscious and can swallow, the most effective way for hypoglycemic coma is to let the patient drink sweet water or eat candy and sweet cakes

invigorate health

invigorate health

2. The effective method for hyperglycemic coma is to drink salted tea or low salt tomato juice

3. If the patient has lost consciousness, place the patient flat and untie the collar to ensure smooth respiratory tract;

[nursing measures]

1. If a diabetic is in a coma, if it is not rescued in time, it is likely to be life-threatening. The nursing staff and family members must observe the patient's condition at any time.

2. Remember the amount of fluid in and out of the patient, such as the amount of drinking water or infusion, urine volume, etc;

3, when the patient is out of danger and regained consciousness, he should actively treat diabetes, adjust his diet and use insulin properly so as to make the body metabolize normal and avoid the recurrence of diabetic coma.

4, diabetes is a chronic disease requiring long-term treatment. Patients and their families need to dispel worries, build confidence and learn knowledge about diabetes, which is of great benefit to patients.

5, in case of prevention, diabetic patients should often carry cards with the words "diabetes" and other cards, and can also record some treatment methods and name and address of the patients, so that they can be referred to others and doctors when they suddenly lose consciousness.