elderly hypoglycemic coma
Introduction
Introduction to low blood sugar coma in the elderly Hypoglycemia refers to a venous plasma glucose concentration of less than 2.8 mmol/L (50 mg/dl), and a coma caused by hypoglycemia is called hypoglycemia coma. The effect of hypoglycemia on the body is mainly nervous system, especially sympathetic nerve and brain. After sympathetic nerve stimulation by hypoglycemia, catecholamine secretion is increased, the latter can stimulate the secretion of glucagon and increase blood sugar level, and Acts on the adrenal receptors and causes tachycardia, irritability, paleness, sweating and elevated blood pressure and other symptoms of sympathetic excitation. Glucose is the main source of energy for the brain, especially the brain, but the brain cells store glucose. The ability is very limited, only can maintain the energy requirements of brain activity for a few minutes. Therefore, the main energy source of the brain is blood sugar. The long-term severe hypoglycemia can seriously damage the brain tissue, and the brain tissue may be congested in the early stage of sugar deficiency. More bloody ecchymoses and then the brain cell membrane Na+/K+ pump is damaged, Na+ enters the brain cells in large quantities, and then cerebral edema and brain tissue punctate necrosis appear. basic knowledge The proportion of illness: the incidence rate of diabetes patients is about 5% Susceptible people: the elderly Mode of infection: non-infectious Complications: epilepsy
Cause
The cause of hypoglycemia and coma in the elderly
Common causes of fasting hypoglycemia in the elderly are:
1 islet B cell tumor (insulinoma); 2 extra-islet tumor; 3 exogenous insulin, oral hypoglycemic agents; 4 severe liver disease; 5 ethanol; 6 pituitary, adrenal insufficiency and so on.
2. Common causes of postprandial hypoglycemia in the elderly:
1 after most of the stomach resection (trophic hypoglycemia); 2 ethanol; early stage 32 diabetes; 4 pituitary, adrenal insufficiency and so on.
(two) pathogenesis
The effect of hypoglycemia on the body is mainly nervous system, especially sympathetic nerve and brain. After sympathetic nerve stimulation by hypoglycemia, catecholamine secretion is increased, the latter can stimulate the secretion of glucagon and increase blood sugar level, and Acts on the adrenal receptors and causes tachycardia, irritability, paleness, sweating and elevated blood pressure and other symptoms of sympathetic excitation. Glucose is the main source of energy for the brain, especially the brain, but the brain cells store glucose. The ability is very limited, only can maintain the energy requirements of brain activity for a few minutes. Therefore, the main energy source of the brain is blood sugar. The long-term severe hypoglycemia can seriously damage the brain tissue, and the brain tissue may be congested in the early stage of sugar deficiency. More bloody ecchymosis; and then due to damage to the brain cell membrane Na+/K+ pump, Na+ enters the brain cells in large quantities, followed by cerebral edema and punctate necrosis of the brain tissue. In the late stage, nerve cell necrosis occurs and disappears, forming brain tissue softening. Different parts of the nervous system have different sensitivities to hypoglycemia, including cerebral cortex, hippocampus, cerebellum, caudate nucleus and globus pallidus. Sensitive, followed by the cerebral nucleus, thalamus, hypothalamus and brainstem, the sensitivity of the spinal cord is low. Some foreign studies have found that hypoglycemia damages the brain similar to the ischemic damage of the brain, but not identical, but Severe hypoglycemia is often accompanied by a decrease in the oxygen uptake rate of the brain tissue, while the brain is less tolerant to hypoxia, which further exacerbates the damage of the hypoglycemia to the brain.
Prevention
Elderly people with hypoglycemia and coma prevention
For diseases with any signs of ketoacidosis, exercise should be prohibited. For patients with elevated blood sugar during exercise, it is not suitable for exercise. When the fasting blood glucose of severe diabetics is above 16.8mmol/L (300mg%), exercise may easily cause ketoacidosis. Therefore, to avoid exercise, special attention should be paid to preventing hypoglycemia in such patients. When exercising, avoid the peak time of the drug. If necessary, carry sugary food with you. If you have symptoms of hypoglycemia, you can take it at any time.
Complication
Elderly hypoglycemic coma complications Complications
The main complications are tachycardia, elevated blood sugar, and impaired brain function.
Symptom
Old people with hypoglycemia and coma symptoms Common symptoms Unconsciousness, coma, weakness, nausea, pale, madness, forgetfulness, trembling, drowsiness, convulsions
1. Sympathetic nervous performance:
This group of symptoms is more obvious when blood sugar drops faster, and adrenaline secretion is more obvious. It is a kind of compensatory reaction caused by hypoglycemia, mainly including sweating (about 1/2, cold sweat is more common), tremor (about 1 /3), blurred vision, hunger, weakness (about 1/4 to 1/3), and nervous, pale, palpitations, nausea and vomiting, cold limbs and so on.
2. The performance of central nervous system inhibition:
This group of symptoms is more common in slower and longer-lasting blood glucose, and the clinical manifestations are diverse, mainly central nervous system hypoxia, hypoglycemia group, the higher the central nervous system, the earlier the inhibition, and the later the recovery, the main performance for:
1 cerebral cortex is suppressed; consciousness is blind, directional force and recognition power is gradually lost, headache, dizziness, forgetfulness, language disorder, lethargy or even coma falls, sometimes mental disorders, fear, panic, hallucinations, mania, etc.;
2 The subcortical center is inhibited; unconscious, restless, may have clonic, dance or naive movements, tachycardia, dilated pupils, paroxysmal convulsions, positive pyramidal tract signs, etc., patients may appear Epilepsy symptoms;
3 cerebral palsy is suppressed; deep coma, degenerative cerebral, all kinds of reflexes disappear, weak breathing, blood pressure drops, dilated pupils, such a condition lasts longer, the patient is not easy to recover.
If the brain tissue is in a relatively severe hypoglycemia state for a long time, cell necrosis and liquefaction may occur, and the brain tissue may be atrophied. The patient often has memory loss, mental retardation, mental disorder or personality variability.
3. Mixed performance:
That is to say, the patient has both the expression of sympathetic excitation and the inhibition of the central nervous system. This type is more common in clinical practice.
4. Symptoms of the primary disease:
Such as liver disease, malignant tumors and serious infections, multiple endocrine neoplasia still have the performance of pituitary tumors and parathyroid diseases.
Examine
Examination of hypoglycemia and coma in the elderly
1. Blood sugar:
Hypoglycemia is a critical condition. First, the patient's blood glucose must be measured quickly and accurately. The suspected patient does not have to wait for the biochemical analysis result. The treatment should be performed immediately after the specimen is taken. When the condition is met, the rapid determination and the biochemical test are performed simultaneously.
Normal human venous plasma glucose concentration, after fasting overnight, <3.3mmol / L (50mg / dl) suggests hypoglycemia, due to individual differences in the diagnosis of hypoglycemia should be a range rather than a specific value, this The range should be 2.5-3.3 mmol/L (45-60 mg/dl) and less than 2.5 mmol/L, and it was confirmed by repeated measurement that hypoglycemia was confirmed.
2. Other inspections:
Other laboratory tests are not necessary for every patient with diabetes mellitus and hypoglycemia.
(1) Glycosylated hemoglobin (GHB): HBAc is the main product of hemoglobin binding to glucose, which can reflect the average blood glucose level in the past two months. The normal value of HBAc is 4% to 6%, and it is treated with intensive insulin for a long time. In patients with type 1 diabetes, HBAc values are inversely related to the incidence of hypoglycemia, HBAc < 6%, and the incidence of hypoglycemia is significantly increased. Therefore, it is more suitable to maintain HBAc between 6% and 7%. Blood sugar patients relax their control of blood sugar, keeping HBAc at around 8.0% for 3 months, which can partially reverse the anti-regulatory effects of impaired hypoglycemic hormone and reduce the incidence of undetected hypoglycemia.
(2) Determination of liver and kidney function: Liver and kidney dysfunction can significantly increase the chance of hypoglycemia. For diabetic patients, it is necessary to fully understand liver and kidney function, choose reasonable treatment, reduce the incidence of hypoglycemia, and also help those with low blood sugar. Etiology analysis.
(3) Determination of blood ketone body, lactic acid and osmotic pressure: helpful for identification with DKA, HHC and lactic acidosis.
If the brain function is impaired, it should be further examined. CT and EEG can be performed to determine the location of the lesion.
Diagnosis
Diagnosis and diagnosis of hypoglycemia and coma in the elderly
diagnosis:
According to the history and clinical manifestations, once suspected hypoglycemia coma, immediately blood tests for blood sugar, such as blood glucose <2.8mmol / L can be diagnosed.
Differential diagnosis:
1. Hypoglycemia that has not been diagnosed:
It should be differentiated from epilepsy, schizophrenia, snoring and various cerebrovascular diseases. There is no hypoglycemia in the above diseases.
2. Those who have established hypoglycemia should be differentiated from hypoglycemia caused by different causes.
(1) Reactive hypoglycemia (functional hypoglycemia): The disease is often associated with mood, mild symptoms, and more during the day (more before breakfast or before lunch), not related to hunger, exercise, often in high-sugar diet After the onset, eating more, with obesity, fasting blood glucose, OGTT, fasting test, D860 and other stimulation tests were negative.
(2) Hepatogenic hypoglycemia: low blood sugar episodes in the early morning fasting, hunger or exercise to promote the onset, the condition is progressive, fasting blood glucose is normal or below normal, OGTT is a diabetic-like curve, but after taking sugar for 4 to 7h Low blood sugar, low-sugar diet can be induced, and the fasting test is positive. These patients are accompanied by severe liver disease and abnormal liver function.
(3) Islet B cell tumor: typical hypoglycemia episodes, mostly in the early morning, hunger and exercise promote seizures, the condition is progressively aggravated, blood sugar is very low at the onset, OGTT, blood glucose is a low-flat curve, serum insulin, C-peptide, insulin The original concentration was significantly increased; the fasting test, D860 and other excitation tests were positive.
(4) drug-induced hypoglycemia: more often in patients with diabetes, injection of insulin or taking sulfonylureas.
Should pay attention to the medical history, if the insulin injection is excessive, the serum insulin is obviously increased and the C peptide is not elevated. If it is serum insulin, the C-peptide level is increased, and the insulinogen is slightly elevated, supporting the low caused by the sulfonylurea. Glucose, the latter often taking sugar, the blood sugar recovery is slower.
(5) hypoglycemia caused by extra-pancreatic tumor: clinical hypoglycemia episodes are typical, but serum insulin, C-peptide, and proinsulin levels are very low. In recent years, this tumor has been found to secrete excessive IGF-II (insulin-like growth factor-II). ), an increase in serum IGF-II, or an increase in the ratio of IGF-II to IGF-I may assist in diagnosis.
(6) hypoglycemia caused by endocrine diseases: hypopital dysfunction, growth hormone deficiency, adrenal insufficiency (Addison's disease), hypothyroidism and other endocrine disorders, can occur hypoglycemia, but through medical history, clinical manifestations, Various hormone assays, endocrine function tests, can make a definitive diagnosis.
