Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM, where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another frequently asked question from our readers and the question last week was
You can check out the answer to last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer another question from one of our readers and the questions this week is
My brother is in a diabetic coma and had a heart attack! Now he’s not waking up, does he have brain damage?
This question from Cynthia formed part of an email counselling and consulting session with me.
my brother got gravely ill within 10-12 hours, well his sugar was over 1,000 mg/dl(>50 mmol/l) and his body temperature went up to 102F(=39.4C) and he was in pretty bad condition.
My brother is only 52 years old and he has been suffering from insulin dependent Diabetes for many years.
So they now have him on the breathing ventilator, he has a UTI(=Urinary tract infection) now, but before that, one of the ICU doctors told me to go home and start calling the rest of the family to prepare them for the worst, this was on Friday 29th January 2016, today is Sunday 31st January!
According to one of the ICU doctors he had so much of the acid in his blood, they got that under control with fluids and some meds eventually, he also has an arterial blood pressure line as his blood pressure was very low, 100 at the most and it also went down as low as 25 and they started him on blood pressure medications!
So the ventilator was helping him to breathe because of all the problems, the low blood pressure, the high sugar with the ketoacidosis, it was at a 6.4 in his blood(normal Ketone levels are 0.6-1.5), well that cleared up eventually and so they got him stable.
But it turns out that he had a slight heart attack when they tried to take him off the ventilator and get him out of the coma, so they had to leave it in for now!
My concern is he isn’t following commands and no eye opening. They are talking about a balloon procedure for the arteries so my concern is that could he could be brain dead because of all those problems and the heart attack?
Not following commands no eye opening no body movement, but they told me he did open his eyes before the heart attack and he has delayed response?
Which I don’t think so, I’m so afraid he’s going to have some kind of brain damage, so what should I be asking the doctor?
As I know my brother doesn’t want to be in any vegetation state or not a normal life, how long should I address of trying again with the ventilator?
Thank you so much if you could respond as soon as possible because I don’t want him to suffer at all.
thank you for your question and thank you for using my email counselling and consulting service!
So let’s just look at the bigger picture here first before I address your questions in detail.
Your brother has long- standing diabetes and is Insulin dependent. He went into a hyperglycaemic diabetic coma with high blood sugars, Ketoacidosis and low blood pressure.
He’s now in Intensive Care in a coma, on a ventilator and he had a small heart attack and you are worried that he has some sort of brain damage or that he may even be brain dead.
The doctors have told you to rally the rest of the family to “prepare for the worst…”
Now, let’s look at what has really happened and let’s look at how to interpret the information that you have accurately.
- A Diabetic coma is a reversible form of coma found in people with diabetes mellitus. It is a medical emergency
- When the combination of Diabetic Coma and the Diabetic ketoacidosis (DKA) is advanced enough to result in unconsciousness from a combination of severe hyperglycemia, dehydration, shock and exhaustion it usually leads to coma, mechanical ventilation with a breathing tube and admission to Intensive Care
This is clearly what’s happened to your brother and with his high blood sugars in excess of 1,000 mg/dl(>50 mmol/l) and with his Ketone levels at 6.4 he is clearly at a point where ICU intervention was necessary to safe his live.
Your brother will now need frequent blood tests , especially arterial blood gases and a larger amount of intravenous fluids. An insulin infusion will be required to ensure a reliable source of insulin and the blood sugar level (BSL) will be checked frequently. This will be done hourly to start, then less often as the BSL stabilises and falls.
An Arterial Catheter has been inserted (Arterial line insertion) for frequent blood tests such as Blood sugar levels(BSL) and Electrolyte checks such as potassium and Magnesium, osmolality (blood concentration) and acid-base status.
They can also check arterial blood gases such as Oxygen(O2) and Carbon dioxide (CO2) levels in the blood to make sure your brother is adequately ventilated.
Once the BSL has been controlled a glucose infusion will probably be started to prevent the BSL from falling too quickly.
An indwelling urinary catheter (IDC) will be used to accurately monitor hourly urine output and the amount of ketones in the urine. The amount of ketones in the urine is a good indicator of whether the DKA (Diabetic ketoacidosis) is resolving and your brother’s condition improving.
It sounds to by what you are describing that your brother had a very fast and very critical onset of the Diabetic Coma with his sugars in excess of 1,000 mg/dl(>50 mmol/l) that led him to lose consciousness quickly.
It is what happens when blood sugar levels spiral out of control quickly.
With the low blood pressure your brother would have been started on Inotropes such as Adrenaline, Noradrenaline, Dobutamine and/or Milrinone.
Especially with his blood pressure as low as 25 you have reasons for valid concerns especially in light of his heart attack.
Now, you are concerned about your brother not “waking up” and not following commands yet.
You also want to know what questions you should be asking the doctors. We have created a general resource for what questions you should be asking and you can check it out here
- 7 QUESTIONS YOU NEED TO ASK THE MOST SENIOR DOCTOR/ PHYSICIAN/ CONSULTANT IN INTENSIVE CARE IF YOUR LOVED ONE IS CRITICALLY ILL IN INTENSIVE CARE (plus one bonus question)
Initially, your brother would have been in a “natural coma” as the Diabetic coma and the Ketoacidosis would have let him slip into a natural coma.
Eventually the Intensive Care team might have used additional sedation like Propofol(Diprivan) or Midazolam(Versed) as well as Opioids like Morphine or Fentanyl, especially with the heart attack.
The plan might have been initially to let your brother “wake up” and then he ended up having the heart attack and that’s why they probably decided to “keep your brother asleep” for now.
But they might have also used sedatives and pain killers(Oipoids), to make sure your brother is comfortable.
As it relates to your concerns about brain damage, the first thing that needs to happen is to establish if there was a time in the last 48 hours where there was insufficient oxygen supply to your brother’s brain or not.
This could have also happened before hospital admission when your brother collapsed at home.
But it could have also happened in ICU while his blood pressure was extremely low.
It all depends on whether the brain was at any time hypo-perfused and had lack of oxygen.
In order to establish if any brain damage might have been caused, your brother would need a CT scan of his brain rather sooner than later.
In ICU they should be able to rule out that any brain damage has been caused since your brother has been to Intensive Care due to all the medications and the monitoring they have given him.
If there was any brain damage it would have most likely been outside of hospital when your brother first collapsed due to the time lag between the collapse and getting an ambulance to see him.
But I do think that not “waking up” yet and that not opening eyes after less than 48 hours in Intensive Care is more due to the fact that your brother is critically ill and is probably due to the fact that your brother initially was in a natural coma and then probably got induced into coma.
“Waking up” after an induced coma can rarely be rushed and it takes time. If anything “waking up” after an induced coma is a process and not an event.
We have a very good resource here that is explaining how “waking up” in Intensive Care occurs. Check it out here (click on the link)
- The 5 Mistakes you are unconsciously making if your critically ill loved one is in an induced coma and is not “waking up”!
- The 10 answers to the 10 most frequently asked questions when your loved one isn’t “waking up “ after an induced coma!
As far as your brother’s heart attack goes and as far as future treatment goes, the following should occur.
- As a starting point, the Intensive Care team should be checking a Troponin level. Troponin is a marker in the blood indicating a heart attack due to heart muscle damage
- The Intensive Care team should be performing an ECG, Ultrasound of the heart and they may also consider a TOE (=Transoesophageal echocardiogram)
The results of those tests will indicate how severe the heart attack is.
As next steps, he might have a coronary Angiogram to check out any potential blockages in the coronary arteries indicating if there are blockages and also indicating how much damage has been done to the heart.
If there are significant blockages of the coronary arteries that have led to a heart attack, then balloon or coronary stent therapy(PTCA) might be an option.
If they are talking about balloon therapy, they might also be talking about an Intra-aortic balloon pump (IABP).
This would indicate that your brother would have sustained a severe heart attack with limited cardiac output and poor ejection fraction(=poor contractility of the heart) and the Intra-aortic balloon pump (IABP) could also be used for leading up to cardiac surgery, as well as for stabilising him.
In any case, I think you might want to ask for a CT scan of the brain rather sooner than later to find out if any brain damage has been caused as a next step.
You might also want to find out what happened prior to your brother having gone into a Diabetic coma to make sure there was nothing that could have been prevented in the first place.
I hope that helps.
Please let me know if you have anymore questions.
Wishing you and your family all the very best!
How can you become the best advocate for your critically ill loved one, make informed decisions, get peace of mind, control, power and influence quickly, whilst your loved one is critically ill in Intensive Care?
You get to that all important feeling of making informed decisions, get PEACE OF MIND, CONTROL, POWER AND INFLUENCE when you download your FREE “INSTANT IMPACT” report NOW by entering your email below!
In Your FREE “INSTANT IMPACT” report you’ll learn quickly how to make informed decisions, get PEACE OF MIND, real power and real control and how you can influence decision making fast, whilst your loved one is critically ill in Intensive Care! Your FREE “INSTANT IMPACT” Report gives you in-depth insight that you must know whilst your loved one is critically ill or is even dying in Intensive Care!
Sign up and download your FREE “INSTANT IMPACT” REPORT now by entering your email below! In your FREE “INSTANT IMPACT” REPORT you’ll learn how to speak the “secret” Intensive Care language so that the doctors and the nurses know straight away that you are an insider and that you know and understand what’s really happening in Intensive Care! In your FREE report you’ll also discover
- How to ask the doctors and the nurses the right questions
- Discover the many competing interests in Intensive Care and how your critically ill loved one’s treatment may depend on those competing interests
- How to eliminate fear, frustration, stress, struggle and vulnerability even if your loved one is dying
- 5 mind blowing tips& strategies helping you to get on the right path to making informed decisions, get PEACE OF MIND, control, power and influence in your situation
- You’ll get real world examples that you can easily adapt to your and your critically ill loved one’s situation
- How to stop being intimidated by the Intensive Care team and how you will be seen as equals
- You’ll get crucial ‘behind the scenes’ insight so that you know and understand what is really happening in Intensive Care
- How you need to manage doctors and nurses in Intensive Care (it’s not what you think)
Thank you for tuning into this week’s YOUR QUESTIONS ANSWERED episode and I’ll see you again in another update next week!
Or you can call us! Find phone numbers on our contact tab.
Also check out our Ebook section where you get more Ebooks, Videos and Audio recordings and where you can also get 1:1 counselling/consulting with me via Skype, over the phone or via email by clicking on the products tab!
This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!