Diabetic Coma
Acute impairment of cerebral functions leading to drowsiness and coma may occurs in a case of diabetes mellitus to ketoacidosis, hypoglycemia, hyperosmolarity and lactic acidosis. The first two types are relatively common, and it is vital to differentiate them as the treatment is diametrically oppose.  Coma may also occur in a diabetic patient from causes unrelated to the basic metabolic disorder like cerebral infraction, head injury, cerebral malaria, encephalitis, uraemia etc.

Diabetic Ketoacidosis and coma…. Pathogenesis.

Diabetic  Ketoacidosis is one of the most serious medical emergencies and occurs exclusively in insulin dependent diabetes. The patient may already be a known case of diabetes mellitus or coma may occurs as the first manifestation of the disease. The various precipitating factors include sudden reduction or stoppage of insulin therapy, any infection, digestive disturbances, acute vascular catastrophe.  Diabetic Ketoacidosis arises primarily from severe insulin deficiency coupled with a relative or absolute increase in glucagon concentration. It is characterized biochemically by marked hyperglycemia and accumulation of large amount of ketone bodies due to excessive catabolism of fats. Both acetoacetate and betahydroxybutyrate are strong acids and interact with the buffer system of the body, resulting in fall of plasma bicarbonate concentration and blood pH(acidosis).

Clinical Features.

The usual symptoms heralding the onset of  Ketoacidosis are anorexia, nausea, vomiting and abdominal pain. At this stage the patient may be conscious or may have already developed stupor and coma. Pyrexia is not uncommon and suggest s superadded infection, through leucocytosis, sometimes even marked, can be a feature of diabetic acidosis per se and may not reflect infection.

Management.

The onset of diabetic acidosis is not sudden. It is usually develops over a few hours. Thus there is generally enough time to treat and reverse it, especially if the patient is already under medical care. The principle aims of management of Diabetic Ketoacidosis are A- replacements of fluids, B-appropriate insulin therapy , C- Correction of electrolyte imbalance and D- treatment of precipitating Causes.
The patient of Diabetic Ketoacidosis must take regular exercise to control cholesterol and fats from their body. I suggest to use far infrared saunas for better detoxification of body.  Infrared saunas are used most of the patients of obesity, diabetes and inflammation. This is the cheapest and effective therapy for controlling aliments.

During The past Two decades air travel has become an increasingly common mode of transport, and advice is often sought by patients regarding their fitness to undertake an air journey. This, and the related medicines aspects of air travel are discussed here under.

Most Commercial aircraft cruise at altitudes of 30,000-40,000 feet. If unprotected, the occupants would become unconsciousness within 30 seconds and dead 6-8 minutes  later due to lack of oxygen. However, this does not happen since all the modern aircraft cabins are pressurized between 5000-7000 feet.While this ensures sufficient protection against acute severe hypoxia, nevertheless, the passengers and the crew are still exposed to reduction in partial pressure of oxygen(PO2) to about 70mm Hg(Oxygen saturation about 92%) because of fall in total atmospheric pressure . Pressurization of the cabins to sea level would eliminate the problem of hypoxia, but this is not cost effective.

PHYSIOLOGICAL CONSIDERATIONS

Two adverse factors operate during travel by air:-

Adverse effects of hypoxia:- The earliest level of hypoxia is depression of function of rods in the retina, resulting in decreased proficiency of night vision. Other important effects of hypoxia such as impairment of higher mental facilities, hyperventilation followed by depression of respiratory centre, and cardiovascular dysfunction manifest only at altitudes above 10,000 feet. However, persons already ill due to certain medical disorders are likely to suffer aggravation in their clinical state even at the cruising cabin pressure of 5000-7000feet. Such patients need to be identified and given suitable advice before the air journey.

ADVERSE EFFECTS OF PRESSURE CHANGES:- At an altitude of about 6000feet, gases increase in volume by about 30 % because  of reduced atmospheric pressure. Air trapped within any of the body cavities also undergoes such a physical change. This may be of little consequence in normal persons, but patient with certain diseases like middle ear infection, sinusitis, pneumothorax, or those recovering  from major thoracic or gastrointestinal surgery are particularly at risk. A period of 3-4 weeks should elapse between such surgery and air travel. Likewise, patients who have air trapped within the cranium should not be permitted air travel, and at least 10 days should be allowed for the air to get absorbed.

GENERAL MEASURES & CONCLUSION.

As outlined above, effects of hypoxia associated with air flight are likely to be aggravated in patients already suffering from certain cardiovascular and respiratory disorders. Their problem will be worsened by alcohol  and cigarette smoking before and during the flight. In fact, a heavy smoker may already be at an equivalent altitude of several thousand feet while walking to the aircraft. Patients who are at risk from hypoxia should, therefore, be advised to abstain from both habits before and during flight.

Patients on regular medicines should be advice to remember to carry their emergency medicines in their hand luggage so that they are not embarrassed in the flight to find that their medicines are locked up into the cargo hold.