MINISTRY OF HEALTH PROTECTION OF UKRAINE Vynnitsa national medical university named after M.I.Pyrogov «CONFIRM» on methodical meeting of endocrinology department A chief of endocrinology department, prof. Vlasenko M.V. _________________ “_31_”_august___ 2012 y METHODOLOGICAL RECOMMENDATIONS FOR INDEPENDENT WORK OF STUDENTS BY PREPARATION FOR PRACTICAL CLASSES Scientific discipline Мodule № 4 substantial module №5 Topic Course Faculty Internal medicine Urgent conditions in the clinic of internal medicine Urgent conditions in endocrinology Management the patient with hypoglycemic coma 6 Medical № 1 Vynnitsa – 2012 Subject: Management of hypoglycemic states Urgency: Knowing the course and treatment of emergency conditions under diabetes is mandatory for physicians of all specialties. Treatment of diabetes with insulin and PTSP often accompanied by occurrence of hypoglycemic staniyu. Doctors need to know clearly the signs of hypoglycemia and rapidly to provide assistance in case of hypoglycemic states of different origin. The problem of timely diagnosis and emergency aid in hypoglycemic states are important because the last if untreated leads to high mortality; posthipohlikemichnoyi of encephalopathy and disability. Goal training: to teach students modern tactics to help patients with hypoglycemic states of diabetes and other pathological conditions, in practice apply modern standards of diagnosis and prevention hipohlikemiy, based on patients with diabetes and other nozoformamy in hospital and clinic. The student must know: 1. Classification of emergency conditions 2. Causes and pathogenesis of hypoglycemic coma and 3. Clinical signs of hypoglycemia and hypoglycemic coma 4. Tactics and methods of treatment of hypoglycemia and hypoglycemic coma in diabetes mellitus 5. Features of the course and first aid to the states under hypoglycemic insulinomy paraneoplastychnyh and processes The student should be able to: 1. Possess methods of diagnosis and analysis of data obtained during interviews and direct examination of patients with hypoglycemic states 2. Assign the required examination for the detection of hypoglycemic and hypoglycemic coma states 3. Diagnostics and differential diagnosis of hypoglycemic states and hypoglycemic coma 4. Identify the tactics of treatment and prevention of hypoglycemia, hypoglycemic coma in diabetes mellitus 5. Be an example of ownership deontological principles for sick people and others Classes are held in the form of students' work within small teams at the bedside of a patient with diabetes mellitus (DM) in the department of endocrinology department and intensive care. According to the thorough training program "Internal Medicine" for higher medical institutions III-IV accreditation levels, the organization of the curriculum should provide students run 4.3 in patients with diabetes. During the curation sick student enjoys protocol and fills a patient. Timing practice (5,5 hours): 1. Morning hospital conference - 30 min.; 2. Supervision of patients in the department-2hod.; 3. Clinical analysis of medical history (seminar) -1.5 h; 4. Independent work (study of literature, articles from the past 2 years, design blog, solving problems with step-2) -1.5 hours. Protocol examination, diagnosis, prevention and treatment Part of the Guide to Action Welcome Pryvitaytesya and by introducing the patient Getting Collect passport data of the patient (P.I.P, sex, age, residence, place of employment and profession) Complaints of the patient at the time of the survey and development of hypoglycemia Define and refine patient complaints. In determining complaints of the patient, note the presence of: -Hunger -General weakness -Sweating Limb-shaking -Palpitations -Diplopia -Yawn -Numbness of the lips, tongue -Motor and mental excitement Drunken behavior-human -Unjustified aggression -Zneprytomlennya. 1.Opytuvannya the agencies and systems. 2.Anamnez disease. 3.Anamnez life. Assess the disease, and interviews with agencies and systems. The presence of risk factors and diseases that can cause hypoglycemia: 1. In the history of diabetes. 2. Treatment with insulin and oral medications tsurkoznyzhuvalnymy. 3. Good and malignant tumors of β-cells of islets of Langerhans. 4. Pozapankreatychni tumor. 5. Diseases of the liver and digestive tract. 6. Diseases of the autonomic and central nervous system. 7. Diseases of other endocrine glands. 8. Metabolic disorder. 9. Malnutrition. 10. Considerable physical activity. 11. Jet hiperinsulinizm. 12. Pregnancy and lactation. When examining the physical examination of the patient assessing: 1.Zahalnoho the patient: -Fainting -Retardation -Obnubilyatsiya -Mental and motor agitation -Skin moisture, diffuse sweating. 2.Dyhannya: -Normal -Accelerated -Yawn 3.Oblychchya: Mind-wandering 4.Zinytsi: -Wide 5.Tonus eyeballs: -Normal 6.Yazyk: Net-Wet 7.Tonus muscles: Stiff-limb muscle Tonic-clonic seizures and 8.Patolohichni reflexes: Duplex-reflex Babinskoho 9.Puls: -Accelerated -Tachycardia 10.Arterialnyy pressure: Standard or high11.Reaktsiya introduction of intravenous glucose solution. Test Plan level of glycemia The level of glycosuria Ketonuria Hp A1S C-peptide Laboratory and instrumental investigations 1.Zahalnyy blood -Usually without disabilities -Sometimes leukopenia. 2.Zahalnyy urine: -Ahlyukozuriya Absence of acetoneLow-share. 3.Rezultaty biochemical analysis of blood: -Hypoglycemia <2.7 mmol / l Increase content-IRI (or C-peptide) under insulinomy -Positive test from starvation (test of inhibition of insulin secretion) Treatment I. On to the hospital stage or in the admission department 1. Bolus introduction of 40% glucose solution in quantities of 40-60 ml, the effect, but its lack of dose increases. 2. Preventing potentially fatal complication of acute encephalopathy, Bernice preintroduction of 100 mg of vitamin B1 thiamine bromide -2.0 5% solution. Errors commonly occur when providing emergency care to the pre-hospital stage for patients with hypoglycemia. 1. Rarely performed diagnostic input 40% glucose solution, which is required in assisting comatose patients. 2. Lack of pre-entry 100 mg Thiamine. 3. Because of the lack of opportunities for prehospital phase is carried out determining the level of glycemia and ketonuria. 4. Without sufficient grounds to and put in a large dose of insulin! II.Alhorytm relief hypoglycemia and hypoglycemic coma in a hospital. Light hypoglycemia (Without loss of consciousness, which does not need outside help). 0-3 min. Acceptance in the amount of simple carbohydrates 1.2 XO: 4-5 tsurku lumps in water, or honey, jam (1-2 tablespoons) or 200ml of sweet fruit juice. If hypoglycemia is caused by the introduction of prolonged insulin, then eat an additional 2.1 HO complex carbohydrates (bread, 2.3 tablespoons of oatmeal and potatoes). Severe hypoglycemia (With / or without loss of consciousness, but that requires outside assistance) 0-3 min. 1.B / ink type in 40-80 ml 40% glucose solution. 2.B / m or subcutaneously enter 1 mg glucagon (hipokit, hlyukahen), or 0,5 ml -1% solution of adrenaline. 5-15 min. 1.If the patient came to himself, to re-enter 60 ml 40% glucose solution. 2.B / drip infusion at 5-10% glucose solution. 15-30 min. 1.Za conditions of glucose over 3 mmol / l and fainting: a) I / drip type 100-120 g mannitol. b) I / bolus injected at 2 mg Dexamethasone every 6 hours (to prevent brain edema). Hypoglycemia in children Clinical features and treatment Hypoglycemia in children characterized by peculiarities of course, related to age. About hypoglycemia in newborns suggests: -Reduction glucose <2.2 mmol / l in the first day -Reduction glucose <2.5 mmol / l of 2 nd day. Under normal conditions in newborns at birth reserves of glycogen in the liver and muscles are significant, and the rate of glucose production is 2-3 times higher (per body area) because of hypoglycemia necessary for very good reasons. Clinical symptoms of hypoglycemia in newborns: • adynamia • Refusal of food • hypothermia • Miotoniya muscle • Tremor • Abnormal cry • Seizures • coma Treatment of hypoglycemia in newborns 1. Jet introduction of 20% glucose solution at the rate of 2-4 ml / kg at speeds 1ml/hv, used in severe hypoglycemia with convulsive syndrome. 2. Under conditions of normal use hypoglycemia introduction of a 5% glucose solution with the speed 5mh/kh/hv to normalize blood glucose. 3. In severe cases, if there is a clear hiperinsulinizm dose can be increased to 15mh/kh/hv. 4. Glucocorticoids 5 mg / kg 2 times per day Hypoglycemia in older children Clinical signs of hypoglycemia in older children Symptoms Symptoms neyrohipolikemiyi sympatho-adrenal system Headache, pale skin Feelings of fear sudorrhea Violation of hearing and sight Muscle trembling Failure to increase the concentration of reflexes Drowsiness Elevated blood pressure Paroxysmal tachycardia syndrome Sopor Aggression Coma bulimia Treatment of hypoglycemic coma in children and adolescents 1. Jet introduction of 20% or 40% glucose solution at a rate of 20-40 ml. 2. If not successful after 15 minutes - re-introduction of the indicated dose. 3. If not successful introduction of a 5% glucose solution. Performed before infusion until the child come to life. Independent work 1. The study of literature: - Endocrinology / Ed. Sci. PM Bodnar. - New knyha.-Vinnitsa - 2010.-464. - Endocrinological Ed. Sci. PN Bodnar .- New knyha.-Vinnitsa - 2007.-346. - Order MZ of Ukraine from 08.05.2009 № 574 "On approval protocols of care, specialty "Endocrinology" 2. Preparation of abstract classes on the topic from the article: - "Endocrinology" (Kyiv) - "Problems of Endocrine Pathology" (Kharkov) - International Journal of Endocrinology (Donetsk) - "Clinical Endocrinology and Endocrine Surgery (Kyiv) - Journals therapeutic profile: a) "Lechaschyy doctor" 2003; № 10, p.58-60 b) "Lechaschyy doctor" 2008; № 10, P.43-46 3. Solution tests and situational problems Step-2. 4. Writing reports of clinical analysis of patients (Appendix 1) Tests baseline knowledge 1) Patient V., 20, suffers from diabetes mellitus of 12 years. In the history of the disease course of labile diabetes with frequent hypoglycemia. Treated insulin Humodar R 100 by 10.8 IU 4 times a day. For convenience and concealment of the disease environment itself began to enter drug Humodar B 100 before breakfast 20 IU and 16 IU before bedtime. Then trouble started strong hunger and sweating at night. Condition improved after taking the simple carbohydrates (sweet tea, candy, cookies, what). What is the reason described led to a change in the patient and what is related manifestations of the disease? 1. * The hypoglycemic state 2. With the change in insulin 3. With disease duration 4. From the beginning of sexual life 5. From the psychological dyzadaptatsiyeyu 2) Patient N., 21, suffers from diabetes 5 years, takes insulin Humodar Humodar R and B, total dose of 1942 IU. In 40 min after injection in the morning complained of sweating, weakness, trembling and sweating general. After some time passed out. With what is likely related to patient complaints and fainting. 1. Since hypoglycemia * 2. From the point ketoatsydotychnoyu 3. From the point hiperosmolyarnoyu 4. With cardiac arrhythmias 5. With vegetative denervatsiyeyu heart 3) For hypoglycemia and hypoglycemic coma are characterized by the following laboratory data: 1. Blood glucose <2.7 mmol / l * 2. Blood glucose <3,3-5,5 mmol / l 3. Blood glucose <5.5 mmol / l 4. High plasma osmolarity <320 mmol / l 5. Giperkaliemiya> 6.0 mmol / liter. 4) ambulance on the street delivered to the admissions department of the patient, 26 years in a state of unconsciousness with a diagnosis - alcohol poisoning. Marked clonic seizures, skin moisture, pathological reflexes. Breath normal. On the lateral surfaces of abdominal signs injection. Pulse - 90 for 1 min, AO-145/90 mm Hg What is the most likely preliminary diagnosis? 1. * Hypoglycemic coma 2. Alcoholic coma 3. Ketoatsydotychna coma 4. Drug poisoning 5. Hemorrhagic stroke 5) Patient F, 32 years, received insulin Humodar R-4 times a day. Three days later he was transferred to a new model of treatment - Humodar B-2 times a day. At 3 o'clock in the morning and felt weak, shaky, sweating and fainted. What is the most likely preliminary diagnosis? 1. Hypoglycemic coma * 2. Ketoatsydotychna coma 3. Acute stroke 4. Uremic coma 5. Hiperosmolyarna coma 6) In what terms might be hypoglycemic coma? 1. Urgent * 2. Within one day 3. Within 2-3 days 4. For 12.10 hrs 5. Within 10-15 days 7) determine what a patient with diabetes at the sudden trembling of the body, palpitation, increased sweating, dizziness? 1. Have a sweet drink * 2. Increase the use of mineral water 3. Reduce drinking 4. Increase the amount of protein in the diet 5. Remove from saturated fat diet. Clinical problem for self1) Patient V., 49, suffers from diabetes for 9 years. Hlimepyridom is treated in a daily dose of 6 mg once in the morning. Through work in the country in summer and irregular meal in the afternoon with the significant sweating, pain behind the breastbone and heart zdavlyuyuchoho character heartbeat. Name the most likely cause of painful attacks in patients? 1. Hypoglycemic states * 2. Prolonged operation in the country 3. Irregular meals 4. Big dose of the drug tsurkoznyzhuvalnoho 5. Dehydration. 2) Patient D, 34 years old, suffers from type 1 diabetes for 10 years. During the celebration of drinking 300 ml of spirits (vodka) before eating, then eat very little. After some time, began to behave aggressively toward others without any reason, and then fainted. What is necessary to provide emergency care to the patient? 1. V / jet type in 40-60 ml 40% glucose solution * 2. V / drip type in 5% glucose solution 3. / B type 20 IU insulin + 5% glucose solution 4. V / jet type in 40-60 ml 40% solution of glucose + insulin 30 IU 5. V / drip type in 200ml 3.4% ash. 3) Patient N., 38, detained in hospital unconscious. According to medical emergencies, the patient noted a mental home and motor arousal. During transportation to the hospital suddenly fainted. With a history of disease: many years suffering from type 1 diabetes, insulin treated. Nutrition irregular because of the need of permanent missions. At physical examination: the unconscious, the skin moisture, pupils wide, muscle twitching face; RR-20 in 1 min; PS -90 in 1 min, rhythmic, SC 150/90mm.rt.st. Cardiovascular and respiratory system without singularities. Abdomen soft. Positive symptom Babinskoho. What is the most likely diagnosis? 1. Hypoglycemic coma * 2. Ketoatsydotychna coma 3. Hiperosmolyarna coma 4. Lactic coma 5. Decompensation of diabetes mellitus with acute renal failure. 4) Patient D., 36, turned to the doctor complaining of periodic weakness, hunger, weight gain of 6 kg over the past 2 years. In the morning the doctor came the attack, accompanied by hunger, trembling, and the patient is unconscious. At examination: blood sugar 2.0 mmol / liter. After entering 40ml 40% glucose solution kupirovano attack. What is the most likely diagnosis? 1. Insulinoma * 2. Diabetes mellitus type 1 3. Diabetes type 2 4. Hlyukahonoma 5. Phaeochromocytoma 5) In the admission department TSKL unconscious patient delivered 48 years old. OBJECTIVE: skin moisture on the thighs and shoulders traces of injections. Breathing shallow. Ps-100 for 1 min, rhythmic. AT-160/40 mm.rt. Art. Muscle tone, tendon reflexes increased. Clonic spasm of muscles of extremities. What is the status of the patient is most likely? 1. Hypoglycemic coma * 2. Ketoatsydotychna coma 3. Hiperosmolyarna coma 4. Lactic coma 5. Coma brain associated with stroke. 6) The patient S., 40, who in 1915 suffered from diabetes mellitus type 1 against compensation after taking over anaprylinu tachycardia, prolonged hypoglycemia occur, the approach which he feels. What treatment tactics in this case is the most rational? 1. Replace anaprilin calcium antagonist * 2. Replace anaprilin obzidanom 3. Reduce the dose of insulin 4. Reduce dose anaprilinu 5. Increase the proportion of carbohydrates in the diet.