Diabetic Coma and Pre-coma

78 General Medical Emergencies

3 Start a proton-pump inhibitor if peptic ulcer disease is likely. Give ome-

prazole or pantoprazole 80 mg i.v. followed by an inf usion at 8 mg/h.

(i) There is no supporting evidence for an H 2 -antagonist.

4 Give octreotide 50 g i.v. then 50 g/h if varices are known, or are likely

from the presence of chronic liver disease and portal hypertension. Also give

ceftriaxone 1 g i.v. in chronic liver disease.

5 Arrange for an urgent endoscopy, particularly in patients who have sus -

pected varices, continue to bleed, remain unstable or are aged >60 years.

Contact the intensive care team.

(i) Endoscopy will differentiate the cause of the bleeding and allow

immediate thermal or injection therapy where appropriate, or

banding for varices.

6 Otherwise admit patients who have stopped bleeding and are haemodynam-

ically stable under the medical team, for endoscopy ideally within 24 h.

DIABETIC COMA AND PRE-COMA

Hypoglycaemia rapidly produces coma in people with diabetes, compared with

the slower onset of altered consciousness in diabetic ketoacidosis and hyper-

glycaemic, hyperosmolar non-ketotic syndrome (HHNS).

Diabetic ketoacidosis

DIAGNOSIS

1 Diabetic ketoacidosis (DKA) may occur in a known diabetic person precipi-

tated by infection, surgery, trauma, pancreatitis, myocardial infarction,

cerebral infarction or inadequate insulin therapy, e.g. insulin stopped in an

unwell diabetic patient ‘ because he was not eating’!

2 Alternatively, it may arise de novo in an undiagnosed diabetic, heralded by

polyuria, polydipsia, weight loss, lethargy, abdominal pain or coma.

3 The predominant features arise from salt and water depletion and acidosis,

hence there is dry skin, tachycardia, hypotension (especially postural) and

deep sighing respirations (Kussmaul breathing).

(i) The ketones may be detected on the breath as a sickly sweet,

fruity smell.

Warning: inserting a central venous pressure (CVP) line in a hypotensive,

shocked patient is difficult and dangerous. Leave it until initial transfusion is under

way for a skilled doctor to perform under ultrasound guidance (see p. 476).

!