HypoglycemiaHypoglycemia

Prepared byPrepared by

Abed ShagoraAbed Shagora

In-service Education DepartmentIn-service Education Department

EGHEGH

HypoglycemiaHypoglycemia

Defined as serum glucose less than Defined as serum glucose less than 50-60 mg/dL50-60 mg/dL

Hypoglycemia is cause of 7% of Hypoglycemia is cause of 7% of people arriving to ED for change in people arriving to ED for change in mental statusmental status

PathophysiologyPathophysiology

First defense is decrease in insulin First defense is decrease in insulin secretionsecretion

Glucagon and epinephrine then Glucagon and epinephrine then stimulate hepatic glucose productionstimulate hepatic glucose production

Glycogen reserve is limited and will be Glycogen reserve is limited and will be depleted after 24-48 hours of fastingdepleted after 24-48 hours of fasting

With continued fasting, gluconeogenesis With continued fasting, gluconeogenesis becomes primary source of glucosebecomes primary source of glucose

Clinical FeaturesClinical Features

Common scenario in DM ptCommon scenario in DM pt’’s include s include inadequate food intake, incorrect inadequate food intake, incorrect dosing of meds, increased physical dosing of meds, increased physical exertionexertion

PatientPatient’’s may have a wide range of s may have a wide range of symptoms and signs: lethargy, symptoms and signs: lethargy, change in mental status, agitation, change in mental status, agitation, combativeness and even seizurescombativeness and even seizures

Clinical FeaturesClinical Features

Rapid fall may cause release of Rapid fall may cause release of counter-regulatory hormones such as counter-regulatory hormones such as epinephrine, causing nervousness, epinephrine, causing nervousness, anxiety, nausea and vomiting, anxiety, nausea and vomiting, palpitations and tremorpalpitations and tremor

DiagnosisDiagnosis

Should always be considered with Should always be considered with altered mentationaltered mentation

Rapid bedside testing should be Rapid bedside testing should be performed on all patients that performed on all patients that present as stroke, TIA, seizure present as stroke, TIA, seizure disorder, narcolepsy, psychosisdisorder, narcolepsy, psychosis

TreatmentTreatment

Initial management is administration Initial management is administration of of

1 g/kg body weight of dextrose as 1 g/kg body weight of dextrose as D50%W in adults. This can be D50%W in adults. This can be followed by D10%W at a rate to followed by D10%W at a rate to maintain glucose 100mg/dL or more. maintain glucose 100mg/dL or more.

Oral replacement is best. 300 grams Oral replacement is best. 300 grams of carbohydrates should be given PO of carbohydrates should be given PO as soda, crackers, juicesas soda, crackers, juices

TreatmentTreatment

Glucagon 1mg IM or IV can be given Glucagon 1mg IM or IV can be given if no IV access. But beware, this can if no IV access. But beware, this can take longer than IV glucose, and the take longer than IV glucose, and the condition of alcoholics, elderly condition of alcoholics, elderly and others with depleted and others with depleted glycogen stores will generally glycogen stores will generally not improve with Glucagonnot improve with Glucagon

TreatmentTreatment

Octreotide has been used for Octreotide has been used for treatment of sulfonylurea induced treatment of sulfonylurea induced hypoglycemiahypoglycemia

Administered SQ with initial dose of Administered SQ with initial dose of 50 to 125 mcg.50 to 125 mcg.

Only recommended after initial Only recommended after initial glucose therapy has been initiated.glucose therapy has been initiated.

TreatmentTreatment

Thiamine 100mg should be given as well Thiamine 100mg should be given as well as glucose.as glucose.

Without thiamine in nutritionally Without thiamine in nutritionally deficient ptdeficient pt’’s could precipitate s could precipitate WernickeWernicke’’s encephalopathy s encephalopathy (a (a syndromesyndrome characterised by ataxia, characterised by ataxia, ophthalmoplegia, confusion, and ophthalmoplegia, confusion, and impairment of short-term memory).impairment of short-term memory).