coma diabetico
DESCRIPTION
Coma diabéticoTRANSCRIPT
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• PROTOCOLO DE PROTOCOLO DE MANEJO EN COMA MANEJO EN COMA
DIABETICODIABETICO
Hospital de EmergenciasHospital de Emergencias
Jose Casimiro Ulloa Jose Casimiro Ulloa
ANA. ALVARADO V.ANA. ALVARADO V.
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COMA DIABETICO
• HIPERGLICEMICO
–Cetoacidotico
–Hiperosmolar
• HIPOGLICEMICO
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1. CONCEPTO:COMA CETOACIDOTICO
EMERGENCIA MEDICA ,PRODUCIDA POR LA FALTA ABSOLUTA O RELATIVA DE INSULINA,Y EL AUMENTO DE HORMONAS CONTRARREGULADORAS.
CARACTERIZADO POR HIPERGLICEMIA
CETOSIS O ACIDOSIS.
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2,FACTORES PRECIPITANTES
INFECCION OMISION DE INSULINARECIENTE INICIO DE DMSTRESSBOMBA DE INSULINA GESTACION
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3.FISIOPATOLOGIAINSULINA
HORMONAS CONTRARREGULADORAS
GLUCOGENOLISIS PROTEOLISIS LIPOLISIS
AA AG
GLUCONEOGENEIS
CETOGENESIS
HIPERGLICEMIA RES.ALCALINA
DESHIDRATACION
LACTOACIDOSIS ACIDOSIS
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4.CLINICA
DESHIDRATACION
POLIURIA
HIPOREXIA
HIPOTENSION
RESPIRACION DE KUSSMAUL
FASCIE ERITEMATOSA
LLENADO CAPILAR
DOLOR ABDOMINAL
OBNUBILACION Y COMA
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5. EXAMENES AUXILIARES
GLUCOSA- MONITOREO
HEMOGRAMA
UREA CREATININA
ORINA
EKG
AGA ELECTROLITOS
Rx PULMONES
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6.DIAGNOSTICO
GLICEMIA >300 mg%
C. CETONICOS +
Ph <7.3
ANION GAP >16
OSMOLARIDAD <320
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CALCULOS BASICOS
• ANION GAP 8-16 mEq
Na - (Cl + HCO3)
• OSMOLARIDAD 290 mOm/l
2(Na +k) +GLUCOSA/18
• Na CORREGIDO
Na + 1.6(G-100)/100
• DEFICIT BICARBONATO
(Bi - Ba)PC X0.3
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7. TRATAMIENTO
MEDIDAS GENERALESMONITOREO UCIFLUIDOSINSULINOTERAPIAPOTASIOBICARBONATOANTIBIOTICOS
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a. FLUIDOS
• SOLUCION SALINA 0.9%
1ra HORA 1 LITRO
2da HORA 0.5 -1 LITRO
• *Na >150 ClNa 4.5%
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b. INSULINOTERAPIA
TIPO : corriente, cristalina, rápida
VIA : IM o EV depende PA
SC cambio de fluidos
DOSIS : HORARIA
5 a10 u minidosis 1 a 2 u microdosis
IM O EV INFUSION CONTINUA
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MONITOREO INSULINA
DESCENSO GLICEMIA< 300 mg%
CAMBIO DE FLUIDOSCLNa 9%0 A DEXTROSA 5%
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c. POTASIO
K (s) K mEq/L
< 3 40
4 - 5 20 - 30
>5 CONTROL
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KALIOPENIA
DIURESIS OSMOTICA
ACIDOSIS
ALDOSTERONA
FLUIDOS : DEXTROSA
INSULINOTERAPIA
BICARBONATO
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d.BICARBONATO
DIAGNOSTICOPh < 6.9HCO3 <9
Por c/40 mEq HCO3 + 15-20mEq K
TRATAMIENTO HCO3 =(Bi - Ba ) PC X 0.3 50% DEL DEFICIT LAS PRIMERAS
24 HORAS
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EFECTOS NOCIVOS BICARBONATO
HIPOKALEMIA
HIPOXIA TISULAR
ACIDOSIS PARADOJAL SNC
SOBRECARGA DE SODIO
CETOGENESIS
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8. COMPLICACIONES
HIPOGLICEMIA G <50 mEq/L
HIPOKALEMIA K < 3.5mEq/L
ALCALOSIS HIPERCLOREMICA EDEMA
SDRA
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COMA HIPEROSMOLAR
• INSULINA ENDOGENA– GLUCOGENOLISIS – USO GLUCOSA– PREVIENE LIPOLISIS
• HORMONAS CONTRARREGULADORAS
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PATOGENESIS CHNC
HIPEROSMOLARIDAD
DIURESIS OSMOTICA
DESHIDRATACION’
EXTRACELUILAR INTRACELULAR
F G A. NEUROLOGICA TROMBOSIS
IR CID
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CLINICA CHNC
DESHIDRATACIONSHOCKOBNUBILACION-COMAALT. NEUROLOGICAS FOCALIZACIONRIGIDEZ NUCACONVULSIONESCOMA
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FACTORES DESENCADENANTES
• INFECCIONES
• DROGAS:
CORTICOIDES,DIURETICOS B BLOQUEADORES, DIASOXIDO,DIFENILHIDANTOINA
• CIRUGIA
• QUEMADURAS
• DIALISIS
• STRESS
• ALTA INGESTA CARBOHIDRATOS
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DIAGNOSTICO CHNC
GLICEMIA > 600 mg/%
Ph > 7.3
HCO3 >20
C. CETONICOS (-)
OSMOLARIDAD > 320
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TRATAMIENTO
MEDIDAS GENERALES MONITOREOFLUIDOSINSULINOTERAPIAPOTASIOTRATAR FACTOR
DESENCADENANTE
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COMPLICACIONES
CID
TROMBOSIS EMBOLISMO
IRA- NTA
PANCREATITIS AGUDA
HEMORRAGIA CEREBRAL
SDRA
HIPOKALEMIA
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HIPOGLICEMIA
• GLICEMIA NORMAL
60 -110 mg%
• HIPOGLICEMIA < 50 mg%
• CON O SIN SINTOMAS
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FACTORES PRECIPITANTES
• SOBREDOIS HIPOGLICEMIANTES– INSULINA– ORALES
• AYUNO• EJERCICIO• INSUFICIENCIA RENAL• HEPATOPATIA• TUMORES• ANTICUERPOS
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CLINICA
ADRENERGICOS NEUROGLICOPENICOS PALIDEZ ALT.CONDUCTA DIAFORESIS CEFALEA ANSIEDAD VISION BORROSA TAQUICARDIA CONVULSIONES PALPITACIONES OBNUBILACION TEMBLOR COMA HIPERTENSION
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TRATAMIENTOVIA ORAL: AGUA AZUCARADA ,FRUTA,
DULCES
DEXTROSA 33% 4 a 6 AMPOLLAS EV EN
BOLO
DEXTROSA INFUSION 5 a 10%
HIDROCORTISONA 100 mg c / 8 horas
GLUCAGON 1mg IM
DIETA FRACCIONADA