Hypoglycemia

HYPOGLYCEMIANUR HANISAH ZAINOREN

CONTENTSINTRODUCTION

CAUSES

CLINICAL FEATURES

DIAGNOSIS TREATMENT

DISCHARGE

INTRODUCTION

(1) symptoms consistent with the diagnosis(2) symptoms associated with a low glucose level,

usually <50 mg/dL (<2.7 mmol/L)(3) symptoms resolve with glucose administration

It is clinically defined as follows:

WHIPPLE TRIAD

• Normal :70-99mg/dL , PP: 140mg/dL• Plasma glucose is normally maintained

at 3.6-5.8mmol/L• Cognitive deteriorates at levels

<3.0mmol/L• Symptoms are uncommon >2.5mmol/L

FACTS

Human brain depends on glucose as its primary source of energy

It is unable to synthesize or store glucose (accounting for the common manifestation of

hypoglycemia as altered mental status)

Physiologic response to low blood glucose suppression of insulin secretion release of the counter-regulatory

hormones

Renal clearance of insulin decreases with age, and this may enhance the risk of hypoglycemia in the elderly.

CAUSES

In diabetics, the commonest cause is a relative imbalance of administered versus required insulin/OHA

Common scenarios in diabetics:- inadequate/delayed food intake- excessive insulin administration- increased physical exertion- change in drug therapy- drug interactions- sudden reduction in diet- renal failure

Other causes are:• Alcohol• Addison’s disease• Pituitary insufficiency• Post gastric surgery• Liver failure• Malaria • Insulinomas• Extra-pancreatic tumors• Attempted suicide/homicide (with large doses of

insulin/OHAs)

CLINICAL FEATURES

Neuroglycopenic Autonomic

LethargyConfusionAgitationSeizuresCombativenessUnresponsivenessFocal neurologic deficitsAlterations in consciousness

AnxietyNervousnessIrritabilityNauseaVomitingPalpitationsTremor

Medical conditions that can be mistaken for hypoglycemia

• Stroke• Transient ischemic attack• Seizure disorder• Traumatic head injury• Brain tumor• Narcolepsy

• Multiple sclerosis• Psychosis• Sympathomimetic drug ingestion• Hysteria• Altered sleep patterns and

nightmares• Depression

DIAGNOSIS

The diagnosis can easily be confirmed

using bedside glucose testing

Hypoglycemia should always be considered early as there is a potential cause of

altered mental status

Can mimic any neurological presentations:

coma seizuresacute confusion

isolated hemiparesis

Failure to determine the blood glucose level early in the evaluation can result in a delayed or missed diagnosis with associated morbidity because of CNS injury or unnecessary

invasive procedures and therapies.

TREATMENT

Depends on conscious state and degree of cooperation of patient

1) 5-15g fast acting oral carbohydrate (eg: Lucozade, sugar lumps, Dextrosol, followed by biscuits & milk)

2) Glucagon 1mg: SC, IM or IV– Can be administered by relatives or ambulance crew if difficult

venous access.– Response to this is slower than IV dextrose, need 7-10min until

normal mental status– Will not work with alcoholics, elderly & depleted glycogen store

3) Glucose 10% solution 50ml IV repeated at 1-2min interval until patient fully conscious

4) Glucose 50% solution hypertonic & no more effective than glucose 10% (if used, give into large vein & follow with saline flush)

5) Octreotide (synthetic analog of somatostatin) – Inhibit release of insulin– Used in treatment of sulfonylurea-induced hypoglycaemia – Only consider if doesn’t respond to dextrose

WARNING!• Suggest underlying pathology (stroke),

development of cerebral edema due to hypoglycaemia (high mortality)

• Maintain plasma glucose at 7-11mmol/L

• Contact ICU & consider mannitol or dexamethasone

• CT scan

Persistence of an altered conscious level

DISCHARGE

20 minutes90% patient fully recover in

When hypoglycemic cause is identified & fully corrected, patient can be discharged

after observation at ED & appropriate follow up.

Arrange follow up having considered the following:

Why did this episode occur?

Has there been any recent change of regimen, other drugs, alcohol, etc?

Is the patient developing hypoglycemic unawareness or autonomic dysfunction?

References

• Tintinalli’s Emergency Medicine, A Comprehensive Study Guide, 6th edition, McGraw Hill publication.

• Oxford Handbook of Emergency Medicine, 4th edition, Oxford university press publisher.

THANK YOUPrepared by Nur Hanisah Zainoren

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