What Is a Diabetic Coma? Everything You Need to Know

Dr. Maheen Shahzad, MBBS, FCPS (R)
Executive Member, LDF

Diabetes is a very deadly condition that comes with various complications that include a diabetic coma that happens when sugar in the blood is too low or may rise to a lethal high and results in unconsciousness. The snatching of this condition may be caused by diabetic ketoacidosis, hyperglycemic state, or severe hypoglycemia. A diabetic coma has the capacity to trigger irreparable brain damage or death when it is not treated promptly. Thereby early recognition of warning signs and knowledge of the basis behind the issues is the first step of sufficient prevention and appropriate time of action.

What Is a Diabetic Coma?

A diabetic coma is an emergency that causes a danger to human life in the sense that the patient with diabetes loses consciousness, and the state cannot be reversed to awaken and show any response to stimuli. It comes about due to the dangerously high (hyperglycemia) or low (hypoglycemia) levels of blood sugar and the individual needs to seek medical attention as the condition leads to brain damage or death.

Difference Between Unconsciousness (Coma) and General Symptoms of Diabetes

General Symptoms of Diabetes:

• Typically, they feature excessive thirst, passing urinary volume, exhaustion, blurred vision, the loss of weight of unknown causes, and, in certain cases, hunger.
• These symptoms are the sign of abnormal, however, not life-threatening levels of blood glucose.

Unconsciousness (Diabetic Coma):

• An individual is not responsive at all and is not awakened.
• They fail to react to what they see, hear, touch, and other means of stimulation.
• Coma is a medico-emergency as opposed to the general symptoms and is a state of altered consciousness.

Causes of Coma in Diabetic Patients

There are three main causes of diabetic coma:

Severe Hypoglycemia (Low Blood Sugar Coma)

1. This is caused by excess insulin, not taking meals, too much alcohol intake, or extensive exercises there is no food intake.
2. The brain requires sufficient glucose to be able to operate, and very low levels would result in unconsciousness.

Diabetic Ketoacidosis (DKA)

1. They are most frequent in type 1 diabetes and may emerge in type 2.
2. Occurs when fat is used as fuel instead of glucose, and there is a potentially fatal accumulation of ketones (acids) in the blood.
3. It is regularly instigated by missed shots of insulin or infection.

Hyperosmolar Hyperglycemic State (HHS/Hyperosmolar Nonketotic Coma)

1. Its predominance can be observed in type 2 diabetes, mostly in elderly people.
2. Hyper glycemic conditions: Extremely high sugary contents in blood (usually above 600mg/dl), makes the body lose excessive water and dehydrate severely to coma level.
3. Common triggers are infection, or missed medicine, or too much consumption of sweet drinks/food.

Summary Table: Causes of Diabetic Coma

Main Causes of Diabetic Coma

Severe Hypoglycemia (Low Blood Sugar)

Pathophysiology

• Normal functioning of the brain is reliant on glucose.
• A severe reduction of blood glucose (usually less than 40 mg/dl) causes the brain to lack the energy it requires and results in impaired consciousness and coma after prolonged periods of no correction.
• This can be quite quick and particularly with those that have insulin or some form of insulin-based diabetes.

Risk Factors & Triggers

• Consuming excessive insulin or diabetes drug.
• Missing or postponing meals.
• Physical activity when there is no correct activity – no change in medication and no adjustment in food intake.
• Alcohol (particularly not eating before consuming) because alcohol does not allow release of glucose in normal amounts in the liver.

Diabetic Ketoacidosis (DKA)

(More common in type 1 diabetes)

Pathophysiology

• It happens when the body is unable to process glucose (as a result of a deficiency of insulin) and thus begins to utilize fat as fuel.
• This breakdown of fat forms acids, ketones, that build up in the blood leading to a condition called acidosis (low pH in blood).
• Blood glucose elevations, dehydration and electrolyte disorders further derail brain functioning and blood flow that may lead to coma.

Risk Factors & Triggers

• Missed insulin doses, incorrect insulin use.
• Undiagnosed diabetes.
• Acute illness or infection (increases insulin demand).
• Emotional or physical stress.
• Injury or surgery.

Hyperosmolar Hyperglycemic State (HHS)

(More common in type 2 diabetes, especially older adults)

Pathophysiology

• It is marked by blood glucose levels that are very high (usually exceeding 600 mg/dL), which cause cells to lose a lot of water (osmotic diuresis).
• The dehydration becomes extreme, the blood becomes highly concentrated (“hyperosmolar”) and the brain degrades.
• low or no ketone generation (as in DKA), however there is still a case that can lead to coma due to dehydration and electrolyte imbalance.

Risk Factors & Triggers

• Poorly controlled or undiagnosed type 2 diabetes.
• Infection (like urinary tract infection or pneumonia).
• Missed or inadequate diabetes medication.
• Severe dehydration (due to illness, heat waves).
• Certain medications (steroids, diuretics).

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Diagnosis and Medical Evaluation

Diagnosis and medical evaluation of diabetic coma involve several key steps and tests to identify the cause and guide urgent treatment:

Blood Glucose Testing

It takes a sample of blood to determine the level of the current blood sugar. This is necessary to ascertain whether the coma has resulted because of acute hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Urine Tests (Ketones)

A urinalysis is done to snake out ketones in the urine, meaning diabetic ketoacidosis (DKA ) – which is a life-threatening cause of diabetic coma particularly in type 1 diabetes.

Blood pH and Electrolyte Levels

• Testing Arterial blood gas (ABG) is carried out to determine the blood pH and check out the presence of metabolic acidosis that is present in DKA.
• Electrolyte panels monitor the levels of concentrations of sodium, potassium, bicarbonate, and other minerals required in the body cell functioning and normally obstructed in diabetic coma.
• Kidney system may also be assessed through blood tests (creatinine, and blood urea nitrogen) since dehydration and imbalance in the electrolytes influence kidney status.

Medical Imaging or ECG (if needed)

• X-rays, CT scans, or MRI imaging studies can be implemented to eliminate another factor that could result in unconsciousness, such as stroke, brain hemorrhage, or some infections.
• ECG (electrocardiogram) may be conducted to check the heart functioning since there may be electrolytic imbalances that can interfere with heart muscles of the heart.

Clinical Evaluation

• Diagnosis also requires proper physical examination, assessment of neurological status, and recount of medical history (including management of diabetes, recent medications, infections, or patients who have forgotten taking insulin) to complete the diagnosis.

Treatment Options

Depending on the cause of the diabetic coma (hypoglycemia, diabetic ketoacidosis [DKA], or hyperosmolar hyperglycemic state [HHS]), treatment of diabetic coma consists of emergency care measures such as:

1. Emergency Care Protocols

On-the-spot request of medical assistance.

• In a person who is unconscious, nothing should be given orally because of choking.
• Move him or her to the recovery position (side) to maintain the airway clear.
• Do not administer insulin or any other medicines without medical supervision.
• Install glucagon shot in suspecting hypoglycemia in the presence of glucagon.Glucose Administration (for Hypoglycemia)
• If conscious and able to swallow, treat mild hypoglycemia with fast-acting carbohydrates like glucose tablets, sugary drinks, or fruit juice.
• For severe hypoglycemia causing unconsciousness:

1. Administer glucagon injection (1 mg) intramuscularly or subcutaneously if available.
2. Alternatively, give intravenous (IV) glucose/dextrose (e.g., 25-50 mL of 50% dextrose) to rapidly raise blood sugar levels.
3. Intravenous Fluids, Insulin, and Electrolyte Correction (for DKA and HHS)
   • Correct dehydration by starting an aggressive IV fluid resuscitation using isotonic saline.
   • IV insulin drips to instantly lower the amount of glucose in the blood and eliminate the ketoacidosis (in DKA).
   • Monitor and replace electrolytes especially potassium, sodium and phosphate to avoid complication in the heart and brain functions.
   • Treat the underlying causes like infections.
4. Hospitalization and Monitoring
   • Diabetic coma patients should be confined in the hospital where they could be monitored closely in terms of vital signs, blood glucose, electrolytes, acid-base status as well as in urine output.
   • Heart monitoring or ECG is required because of the possibility of arrhythmia development under the influence of electrolyte imbalances.
   • Regular lab tests (glucose, electrolytes, blood gases) determine further changes in the treatment.
   • Severe cases might require admission to the intensive care unit (ICU), particularly in case of HHS or complicated DKA.

All these measures in treatment are intended to correct the life-threatening metabolic imbalances in time and act against such complications as cerebral edema, cardiac arrhythmias, or organ failure.

Final Thoughts

To conclude, diabetic coma is one of the vital emergencies that may occur due to either overly high or low levels of blood sugar. The difference could be based upon learning its causes, i.e. diabetic ketoacidosis, hyperosmolar hyperglycemic state or hypoglycemia, as well as being aware of its early symptoms that could have potentially fatal consequences. An awareness creation on this condition is a necessity because it is a potentially life-saving intervention that can prevent the occurrence of long-term complications. Whether an individual has medical diabetes or is taking care of a person who has diabetes it is crucial to reach a healthcare expert on a regular basis to make sure that the condition is under control as well as advise.