HYPOGLYCEMIA

by Valeria Wu

SYMPTOMS (likely to present when glucose < 70)

- Tremors, palpitations, anxiety, sweating, hunger, paresthesias, diaphoresis

- Dizziness, weakness, drowsiness, delirium, confusion, vision disturbance

- Severe: coma and seizure

“Whipple’s Triad” - hypoglycemia symptoms, plasma glucose < 55 mg/dL, resolution of symptoms after glucose given

CAUSES

- Medications (sulfonylureas, insulin secretagogues, beta blockers, APAP, ACEi)

- Alcohol

- Infection

- Starvation

- Hormone deficiency

- Insulin disorders

- Critical illness, organ failure

TREATMENT

Adults

- Conscious and not altered?

- Oral glucose

- 15 - 20g of fast acting carbs!

- Juice, honey, sugar, hard candies, raisins

- 15 g glucose gel

- Consider glucose tablets if patient taking multiple diabetic meds

- Severe and altered?

- IV

- D50 ampule (25g glucose)

- No IV

- Glucagon (IM/SQ 1mg, IN 3mg)

- Glucose gel/sugar paste/frosting buccal or between teeth if no glucagon

- Monitor

- Check accucheck Q30 min - Repeat sooner if needed

- Consider infusion (D10 1/2NS drip (100mL/hr)) if not responsive

- Consider octreotide for sulfonylurea poisoning

- Adults 50-100 mcg subQ Q6H or 50-125 mcg/hr

- Pediatrics 2 mcg/kg (max 150mcg) subQ

Pediatrics

- Mild - moderate

- Simple carb for quick acting sugars, followed by more complex

- Check sugar 15-20 minutes after

- If cannot tolerate PO - Glucagon: 0.03mg/kg IM/SQ/IV, repeat Q20min as needed

- Severe:

- 1ml/kg of D50W (adolescent)

- 2mL/kg D25W (infant/child)

- 5mL/kg D10W (neonate/infant)

** remember the “50” rule **

References

Carlson JN, Schunder-Tatzber S, Neilson CJ, Hood N. Dietary sugars versus glucose tablets for first-aid treatment of symptomatic hypoglycaemia in awake patients with diabetes: a systematic review and meta-analysis. Emerg Med J 2017; 34:100.

Fasano CJ et al. Comparison of Octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med 2008; 51:400-406

Jalili M. Type 2 Diabetes Mellitus In: Tintinalli's Emergency Medicine. 7th ed. McGraw Hill. 2011:1431-1432