ETIOLOGI KOMA

• GLYCEMIA-RELATED • NON-GLYCEMIA
• Hypoglycemia RELATED
• Hyperglycemia : • Meningitis
Ketoacidosis • Stroke
• Hyperglycemia :HHNKC • SDH
• Associated
encephalopathy
Lipid Metabolism
 Islets of b-cell destruction Insulin Deficiency
Langerhans

Decreased Glucose Utilization &

Increased Production
Stress

Muscle
Amino Glucagon
Adipo- Increased
Acids Liver
cytes Protein
Catabolism
Increased
Ketogenesis
Gluconeogenesis,
FattyAcids Glycogenolysis
IncreasedLipolysis

Polyuria Threshold
180 mg/dl Hyperglycemia
Volume Depletion
Ketoacidosis
Ketonuria
HyperTG
Pathophysiology
Glucagon
Epinephrine
Cortisol
Insulin Growth Hormone
Pathophysiology
Glucagon
Epinephrine
Insulin Cortisol
Growth Hormone

Dec Glucose Utilization

Lipolysis
Pathophysiology
Glucagon
Insulin
Epinephrine
Cortisol
Growth Hormone

Gluconeogenesis
Glycogenolysis
Lipolysis
Ketogenesis
 KESEIMBANGAN ASAM BASA
• Normal plasma darah PH: 7,35-7,45
• PH tubuh dipengaruhi oleh:
– Hidrogen ion ( H ion)
– CO2
– bikarbonat
• Pengeluaran ion H dalam tubuh tergantung
tiga mekanisme:
– Sistem Buffer
– Pengeluaran CO2 melalui paru
– Eksresi melalui ginjal
 ACID-BASE REGULATION
• Pengendalian pH normal pada cairan
extracellular dilakukan dengan 3 mekanisme:
– 1) Chemical Buffers
• Reaksi sangat cepat
(< 1 sekon)
– 2) Respiratory Regulation
• Reaksi cepat
– 3) Renal Regulation
• Reaksi lambat (menitjam)
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 ACID-BASE REGULATION

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 Electrolyte Loss

K Intracellular exchange
I K+ of potassium with
D hydrogen ions
N
E H+
Y

Ketoacids draw out intravascular cations

of Sodium and Potassium
Glucose
Phosphorous is also depleted in the osmotic diuresis
Ketoacids
 Elements of Therapy

• Fluids – treat shock, then sufficient to

reverse dehydration and replace ongoing
losses (will correct hyperglycemia)
• Insulin – sufficient to suppress ketosis,
reverse acidosis, promote glucose uptake
and utilization (will stop ketosis)
• Electrolytes – replace profound Na+ and K+
losses
Controversies and Risks of Therapy

• Fluids - composition, bolus

amount and total fluids/day
Cerebral
Edema
• Use of Bicarbonate
• Phosphate replacement
 Cerebral Edema - Therapy
• The best therapy is to prevent it with
careful rehydration.
• Diagnosis available with CT scan.
• Therapy for acute episode:
– Intubation and hyperventilation
– IV Mannitol 0.5 - 1.0 Gram/Kg as bolus.
– IV sedation.
– Slow the rate of osmolar correction.