Diabetic coma

Definition
A coma is a state of unconsciousness. A diabetic coma is a life-threatening
diabetes complication.
If you have diabetes, dangerously high blood sugar (hyperglycemia) or
dangerously low blood sugar (hypoglycemia) can lead to a diabetic coma. If you
lapse into a diabetic coma, you're alive — but you can't awaken or respond
purposefully to sights, sounds or other types of stimulation. Left untreated, a
diabetic coma can be fatal.
The prospect of a diabetic coma is scary, but there's good news. The risk of a
diabetic coma is small — and prevention is in your hands. Start by following your
diabetes treatment plan.
Symptoms
A diabetic coma doesn't strike out of the blue. You'll first experience signs and
symptoms of high blood sugar or low blood sugar.
High blood sugar
If your blood sugar level is too high, you may experience:
■ Increased thirst
■ Frequent urination
■ Dry mouth
■ Nausea
■ Vomiting
■ Shortness of breath
Low blood sugar
If your blood sugar level is too low, you may feel:
■ Shaky or nervous
■ Tired
■ Sweaty
■ Hungry
■ Irritable
■ Confused
Causes
Prolonged blood sugar extremes — blood sugar that's either too high or too low
for too long — may cause various conditions, all of which can lead to a diabetic
coma.
Diabetic ketoacidosis. If your muscle cells become starved for energy,
your body may respond by breaking down fat stores. This process forms
toxic acids known as ketones. Left untreated, diabetic ketoacidosis can
lead to a diabetic coma. Diabetic ketoacidosis is most common in people
who have type 1 diabetes, but it can also affect people who have type 2
diabetes or gestational diabetes.
■Diabetic hyperosmolar syndrome. If your blood sugar level tops 600
milligrams per deciliter (mg/dL), or 33 millimoles per liter (mmol/L), the
condition is known as diabetic hyperosmolar syndrome. When your blood
sugar gets this high, your blood becomes thick and syrupy. The excess
sugar passes from your blood into your urine, which triggers a filtering
process that draws tremendous amounts of fluid from your body. Left
untreated, diabetic hyperosmolar syndrome can cause life-threatening
dehydration and loss of consciousness. Diabetic hyperosmolar syndrome is
most common in older adults who have type 2 diabetes.
■Hypoglycemia. Your brain needs glucose to function. In severe cases, low
blood sugar may cause you to pass out. Hypoglycemia is most common in
people who take too much insulin or skip meals or snacks. Exercising too
vigorously or drinking too much alcohol can have the same effect. How
quickly your blood sugar drops influences the symptoms of hypoglycemia.
For example, if it takes a few hours for your blood sugar to drop 50 mg/dL
(3 mmol/L), the symptoms may be minimal. If your blood sugar drops the
same amount in a few minutes, the symptoms will be more pronounced
Risk factors
Anyone who has diabetes is at risk of a diabetic coma. Risk factors for the
conditions that may lead to a diabetic coma vary, however.
For example, diabetic ketoacidosis is most common in people who have type 1
diabetes. Diabetic hyperosmolar syndrome is most common in older adults who
have type 2 diabetes — especially those who don't monitor their blood sugar or
who don't know they have diabetes.
When to seek medical advice
A diabetic coma is a medical emergency. If you pass out, you'll need someone to
request emergency medical help.
Tests and diagnosis
If you experience a diabetic coma, prompt diagnosis is essential. The emergency
medical team will do a physical exam and may ask those who are with you about
your medical history.
You may need various lab tests as well. The doctor may measure:
Your
 ■ blood sugar level
■ Your ketone level The amount of nitrogen or creatinine (a breakdown product of creatine, an
important part of muscle) in your blood
■ The proportion of red blood cells and fluid in your blood (hematocrit)
■ The amount of potassium in your blood
Complications
Left untreated, a diabetic coma can lead to permanent brain damage. In some
cases, an untreated diabetic coma can be fatal.
Treatments and drugs
Emergency treatment for a diabetic coma depends on whether your blood sugar
level is too high or too low.
If your blood sugar level is too high, you may be given intravenous fluids to
restore water to your tissues. You may need potassium, sodium or chlorine
supplements to help your cells function correctly. When enough fluid has been
replaced, short-acting insulin may be used to help your tissues absorb glucose
again. Any underlying infections will be treated as well
If your blood sugar level is too low, you may be given an injection of the hormone
glucagon. The injection will cause your blood sugar level to quickly rise.
Consciousness typically returns when blood sugar reaches a normal level.
Prevention
Good day-to-day control of your diabetes can help you prevent a diabetic coma.
Keep these tips in mind:
Follow your meal plan. Consistent snacks and meals can help you control
your blood sugar level.
■Keep an eye on your blood sugar level. Frequent blood sugar tests can
tell you whether you're keeping your blood sugar level in your target range
— and alert you to dangerous highs or lows.
■Take your medication as directed. If you have frequent episodes of high
or low blood sugar, your doctor may adjust the dosage or timing of your
medication. Your doctor may recommend regular glycated hemoglobin
tests to determine how well you're managing your blood sugar.
■Educate your loved ones, friends and co-workers. Teach loved ones
and other close contacts how to recognize early signs and symptoms of
blood sugar extremes — and how to summon emergency help should you
pass out.
■Wear a medical ID bracelet or necklace. If you're unconscious, the ID
can provide valuable information to your loved ones, co-workers and others
— including emergency personnel.
■Above all, keep your perspective. For most people who have diabetes, the risk of
a diabetic coma is small. Take good care of yourself to help prevent diabetes complications.

Diabetes mellitus

Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin.
Diabetes is condition in which an insufficient amount of insulin is made.
Typical symptoms include excessive thirst, urination, and fatigue.
The diagnosis is based on symptoms and urine and blood tests.
Treatment includes changes in diet, exercise, weight loss (if overweight), and insulin injections or drugs taken by mouth.
The symptoms, diagnosis, and treatment of diabetes are similar in children and adults (see Diabetes Mellitus (DM): Diabetes Mellitus). However,
management of diabetes in children may be more complex. It must be tailored to the child's physical and emotional maturity level and to constant
variations in food intake, physical activity, and stress.
Insulin is a hormone that is released by the pancreas. Insulin controls the amount of sugar (glucose) in the blood. A child with diabetes has high blood
sugar levels either because the pancreas produces little or no insulin (type 1 diabetes, formerly called juvenile-onset diabetes) or because the body is
insensitive to the amount of insulin that is produced (type 2 diabetes). In either case, the amount of insulin available is insufficient for the body's needs.
Type 1 diabetes can develop at any time during childhood, even during infancy, but it usually begins between ages 6 and 13 years. Type 2 diabetes
occurs mainly in adolescents but is becoming increasingly common in overweight or obese children.
Up until the 1990s, more than 95% of children who developed diabetes had type 1 diabetes, usually because the immune system attacked the cells in
the pancreas that make insulin (islet cells). Such an attack may be triggered by environmental factors in people whose genetic make-up leaves them
susceptible. Recently, the number of children, especially adolescents, with type 2 diabetes has been steadily increasing. Today, 10 to 50% of children
newly diagnosed with diabetes have type 2 diabetes. The increase in childhood type 2 diabetes has been particularly prominent among Native
Americans, blacks, and Hispanics. Obesity and a family history of type 2 diabetes are major factors in the development of type 2 diabetes (but not type
1).
Which Children Are at Risk of Type 2 Diabetes?
Children and adolescents meeting these criteria should be tested with a fasting blood sugar test every 2 years beginning at about age 10:
Being overweight (weighing more than 85% of children of similar age, sex, and height or weighing more than 120% of the ideal weight for height)
Plus any two of the following factors:
Having a close relative with type 2 diabetes
Being Native American, black, Hispanic, or Asian/Pacific Islander
Having high blood pressure, high blood levels of lipids (fats), or polycystic ovary syndrome
In newborns who are very underweight, blood sugar levels may be elevated transiently, usually because they are given intravenous infusions of glucose
too rapidly. The infusions are given to increase the newborn's weight. This problem usually resolves on its own.
Symptoms
High blood sugar levels are responsible for a variety of immediate symptoms and long-term complications.
Symptoms develop quickly in type 1 diabetes, usually over 2 to 3 weeks or less, and tend to be quite obvious. High blood sugar levels cause the child to
urinate excessively. This fluid loss causes an increase in thirst and the consumption of fluids. Some children become dehydrated, resulting in weakness,
lethargy, and a rapid pulse. Vision may become blurred.
Diabetic ketoacidosis occurs at the beginning of the disease in about one third of children with type 1 diabetes. Without insulin, cells cannot use the
sugar that is in the blood. Cells switch to a back-up mechanism to obtain energy and break down fat, producing compounds called ketones as byproducts.
Ketones make the blood too acidic (ketoacidosis), causing nausea, vomiting, fatigue, and abdominal pain. The ketones make the child's
breath smell like nail polish remover. Breathing becomes deep and rapid as the body attempts to correct the blood's acidity (see Acid-Base Balance:
Introduction). Some children develop a headache and may become confused or less alert. These symptoms may be caused by accumulation of fluid in the brain (cerebral edema). Diabetic ketoacidosis can progress to coma and death. Children with diabetic ketoacidosis are also dehydrated and often
have other chemical imbalances in the blood, such as an abnormal level of potassium and high levels of lipids (fats).
Symptoms in children with type 2 diabetes are milder than those in type 1 diabetes and develop more slowly?over weeks or even a few months. Parents
may notice an increase in the child's thirst and urination or only vague symptoms, such as fatigue. Typically, children with type 2 diabetes do not develop
ketoacidosis or severe dehydration.
Diagnosis
Doctors suspect diabetes when children have typical symptoms or when a urine test done during a routine physical examination reveals sugar. The
diagnosis is confirmed by measurement of the blood sugar level. Preferably, the blood test is done after the child fasts overnight. A child is considered
to have diabetes if the fasting blood sugar level is 126 milligrams per deciliter (mg/dL) or higher. Sometimes, doctors also do tests to see whether the
blood is too acidic or contains ketones. Rarely, doctors order a blood test that detects antibodies to islet cells to help distinguish type 1 diabetes from
type 2.
Because prompt measures (such as dietary changes, an increase in physical activity, and weight loss) may help prevent or delay the onset of type 2
diabetes, children at risk should be screened with a blood test. Nothing can be done to prevent type 1 diabetes Breaking Down Sugar
There are many kinds of sugar. The white granules of table sugar are known as sucrose. Sucrose occurs naturally in sugar cane and sugar beets.
Another kind of sugar, lactose, occurs in milk. Sucrose consists of two different simple sugars, glucose and fructose. Lactose consists of the simple
sugars glucose and galactose. Sucrose and lactose must be broken down by the intestine into their simple sugars before they can be absorbed.
Glucose is the main sugar the body uses for energy, so during and after absorption, most sugars are turned into glucose. Thus, when doctors talk about
blood sugar, they are really talking about blood glucose.
Treatment
The main goal of treatment is to keep blood sugar levels as close to the normal range as can be done safely. To control blood sugar, children with type
1 diabetes take insulin, and children with type 2 diabetes take drugs given by mouth. Children with either type of diabetes need to change their diet,
exercise regularly, and, if overweight, lose weight.
When type 1 diabetes is first diagnosed, children are usually hospitalized, and those with diabetic ketoacidosis are treated in an intensive care unit.
Children with type 1 diabetes are given fluids (to treat dehydration) and insulin. They always require insulin because nothing else is effective. Those with
ketoacidosis require insulin intravenously for a brief time. Those without ketoacidosis typically receive two or more daily injections of insulin, although
some children may need to receive insulin continuously by a small infusion pump through a needle under the skin. Insulin treatment is usually begun in
the hospital so that blood sugar levels can be tested often and doctors can change insulin dosage in response. Rarely, treatment is started at home.
Children with type 2 diabetes do not usually need to receive treatment in the hospital. They do require treatment with drugs to lower blood sugar levels
(antihyperglycemic drugs), which are taken by mouth. The drugs used for adults with type 2 diabetes (see Oral Antihyperglycemic Drugs) are safe for
children, although some of the side effects?particularly diarrhea?cause more problems in children. Some children with type 2 diabetes need insulin. A
few children who lose weight, improve their diet, and exercise regularly may be able to stop taking the drugs.
Nutritional management and education are particularly important for all children with diabetes. Because carbohydrates in food are turned into glucose by
the body, variations in carbohydrate intake cause variations in blood sugar levels. Large amounts of sugar, as is present in soda, candy, and pastries,
are discouraged because blood sugar may rise too high. Parents and older children are taught how to gauge the carbohydrate content of food and
adjust what children eat as needed to maintain a consistent daily intake of carbohydrates. Children of all ages may find it difficult to consistently follow a
properly balanced meal plan (consumed at regular intervals) and avoid the temptations of sugary snacks. Infants and preschool-aged children present a
particular challenge to parents because of the concern arising from the dangers of frequent and very low blood levels sugar (hypoglycemia).
Adolescence: Adolescents may have particular problems controlling their blood sugar levels because of:
Hormonal changes during puberty: These changes affect how the body responds to insulin. As a result, higher doses are usually needed during this
time.
Adolescent lifestyle: Peer pressure, increased activities, erratic schedules, concern about body image, or eating disorders may interfere with the
prescribed treatment regimen, particularly their meal plan.
Experimentation with alcohol, cigarettes, and illicit drugs: Adolescents who experiment with these substances may neglect their treatment regimen.
Conflicts with parents and other authority figures: Such conflicts may make adolescents less willing to follow their treatment regimen.
Thus, some adolescents need for a parent or another adult to recognize these issues and give them the opportunity to discuss problems with a health
care practitioner. The practitioner can make sure adolescents remain appropriately focused on keeping their blood sugar levels under control. Parents
and health care practitioners should encourage adolescents to check their blood sugar levels frequently.
Support: Emotional issues affect children with diabetes and their families. The realization that they have a lifelong condition may cause some children to
become sad or angry, and sometimes even deny that they have an illness. A doctor, psychologist, or counselor needs to address these emotions to
secure the child's cooperation in adhering with the required regimen of meal plan, physical activity, blood sugar testing, and drugs. Failure to resolve secure the child's cooperation in adhering with the required regimen of meal plan, physical activity, blood sugar testing, and drugs. Failure to resolve
these issues can lead to difficulties with blood sugar control.
Summer camps for children with diabetes allow these children to share their experiences with one another while learning how to become personally
more responsible for their condition.
For the treatment of diabetes, the child's primary care doctor usually enlists the aid of a team of other professionals, possibly including a pediatric
endocrinologist, dietitian, diabetes educator, social worker, or psychologist. Family support groups may also help. The doctor may provide parents with
information to bring to school so that school personnel understand their roles.
Did You Know...
Type 2 diabetes is almost always associated with obesity.
Monitoring Treatment: Children and parents are taught to monitor the blood sugar level at least 4 times a day using a blood sample obtained by pricking
a fingertip or the forearm with a small implement called a lancet. Once experience is gained, parents and many children can adjust the insulin dose as
needed to achieve the best control. In general, by 10 years of age, children start to become interested in testing their own blood sugar levels and
injecting insulin themselves. Parents should encourage this independence but make sure the child is being responsible. Doctors teach most children
how to adjust their insulin dosage in accordance with the patterns of their home blood sugar records.
Children with diabetes typically see their doctor 4 times a year. The doctor evaluates their growth and development, reviews blood sugar records that the
family member keeps, provides guidance and counseling about nutrition, and measures glycosylated hemoglobin (hemoglobin A1c)?a substance in the
blood that reflects blood sugar levels over the long term. The doctor screens for long-term complications (see Diabetes Mellitus (DM): Complications)
once a year by measuring protein in the urine, assessing function of the thyroid gland, and performing neurologic and eye examinations.
Some children with diabetes do very well and control their diabetes without undue effort or conflict. In others, diabetes becomes a constant source of
stress within the family, and control of the condition deteriorates. Adolescents in particular often find it difficult to follow the prescribed treatment regimen
given the demands on their schedule and the limitations on their freedom that arise from diabetes. An adolescent benefits if the doctor considers the
adolescent's desired schedule and activities and takes a flexible approach to problem solving?working with the adolescent rather than imposing
solutions.
Did You Know...
Children with type 1 diabetes always need insulin injections, regardless of whether they lose weight or change their diet.
Complications of Treatment and Illness: No treatment completely maintains blood sugar at normal levels. The goal of treatment is to avoid blood sugar
levels that are too high and too low. The complications of diabetes include coronary artery disease, kidney failure, blindness, peripheral vascular
disease, and other serious disorders. Although these events take years to develop, the better the control of diabetes, the less likely that complications
will ever occur.
Low blood sugar (hypoglycemia (see Hypoglycemia) occurs when too much insulin or too much of an antihyperglycemic drug is taken or when the child
does not eat regularly or engages in unusually vigorous and sustained exercise. Hypoglycemia produces weakness, confusion, and even coma. In
adults, adolescents, and older children, episodes of hypoglycemia rarely cause long-term problems. However, frequent episodes of hypoglycemia in
children younger than 5 may permanently impair intellectual development. Also, young children may not be aware of the warning symptoms of
hypoglycemia. To minimize the possibility of hypoglycemia, doctors and parents monitor young children with diabetes particularly closely and use a
slightly higher target range for their blood sugar level.
Children and adolescents with type 1 diabetes who miss insulin injections may develop diabetic ketoacidosis within days. The long-term insufficient or
inadequate use of insulin can lead to a syndrome of stunted growth, delayed puberty, and an enlarged liver (Mauriac syndrome).