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Metabolic Encephalopathy

Hendra Zufry

Division of Endocrinology, Metabolism & Diabetes


Dept.of Medicine, School of Medicine, Syiah Kuala University/
Dr. Zainoel Abidin General Hospital

DD/ Encepalopathy?

APPROACH TO THE PATIENT IN


COMA
Comprehensive history & examination
The neck should be stabilized in all instances of
trauma
until cervical spine fracture or subluxation can be ruled
out
in unconscious patients with a history of trauma,
peritoneal lavage by an experienced surgeon may be
warranted

Causes of Coma
More than half of all cases of coma are due to
metabolic brain dysfunctions.

Differentiating Toxic-Metabolic Coma from


Structural Coma
When the history is available, the patient's underlying illnesses
and medications, or the setting in which they are found, often
help guide the physician to the appropriate cause
The time course of the illness resulting in coma can be helpful.
Generally, structural lesions have a more abrupt onset,
whereas metabolic or toxic causes are more slowly progressive
The response to initial emergency therapy may help
differentiate metabolic or toxic causes of coma
In general, structural lesions have focal features or at least
notable asymmetry on neurological examination. Toxic,
metabolic, and psychiatric diseases are characterized by their
symmetry

1. Diabetic Ketoacidosis (DKA)

2. Hyperosmolar Hyperglicemia
State (HHS)
<1% of all diabetes-related
admissions
More common in elderly & Type 2
diabetics
Mortality
Variable 10-50%
Most often due to the precipitating illness

Causes of DKA/HHS
New diagnosis of Diabetes
Infection: Pneumonia, Gastroenteritis,
UTI
Pancreatitis
Acute MI/ACS
Stroke
Trauma
Alcohol/Drugs/Medications
Missed Insulin/Compliance

Evaluation in DKA/HHS
Laboratory

Glucose
Electrolytes
CBC
Serum Ketones
Plasma Osmolality
ABG (?venous pH)
Urinalysis
?Amylase/Lipase

Other

Electrocardiogram
Chest X-Ray
Blood Culture
Urine Culture
Sputum Culture

Treatment of DKA/HHS
Initial Evaluation: ABCs; Exam; Labs;
Causes
Close Monitoring
Fluid Replacement
Insulin Therapy
Electrolyte Replacement
Resolution & Conversion to home
therapies

3. Hypoglycemia
Mild: Adrenergic (BG<70)

(<4mmol)

Moderate: Cognitive (BG<50)


(<3mmol)

Severe: Unconscious (BG ???)


Remember : Trias Wipple

Hypoglycemia:
Targets/Goals
Unable to recognize &
verbalize lows: >80 mg/dl
(4.5 mmol)

Able to recognize &


verbalize lows: >70 mg/dl
(4 mmol)

Pregnancy: >60 mg/dl

(3.3

mmol)

<10% of readings below


target at each time of day
No severe lows

Hypoglycemia
Prevention Strategies
Consistent Monitoring
Before All Meals & Snacks

Pre/Post Exercise
Bedtime
3 a.m. (occasionally)

4. Hepatic encephalopathy (HE)

It represents a reversible decrease in neurologic


function, based upon the disorder of metabolism
which are caused by severe decompensated liver
disease

Clinical stages of HE

Clinical stages of HE

Strategy for the management of HE


Identify and correct the precipitating cause(s)
Initiate ammonia-lowering therapy
Minimize the potential medical complications
of cirrhosis and depressed consciousness

5. Hyponatremia
Definition:
Commonly defined as a serum sodium concentration
135 meq/L
Hyponatremia represents a relative excess of water in
relation to sodium.

Hyponatremia..
Epidemiology:
Hyponatremia is the most
ocw.jhsph.edu
common
electrolyte disorder
incidence of approximately 1%
prevalence of approximately 2.5%
surgical ward, approximately 4.4%
30% of patients treated in the intensive
care unit

Hyponatremia
Types
Hypovolemic hyponatremia
Euvolemic hyponatremia
Hypervolemic hyponatremia

Hyponatremia
Treatment
four issues must be addressed

Asyptomatic vs. symptomatic


acute (within 48 hours)
chronic (>48 hours)
Volume status

1st step is to calculate the total body


water
total body water (TBW) = 0.6 body weight

Treatment Cont..
next decide what our desired correction rate
should be
Symptomatic
immediate increase in serum Na level by 8 to 10
meq/L in 4 to 6 hours with hypertonic saline is
recommended

acute hyponatremia
more rapid correction may be possible
8 to 10 meq/L in 4 to 8 hours

chronic hyponatremia
slower rates of correction
12 meq/L in 24 hours

Thanks