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KembaraXtra-Emergency And Acute Medicine: Hypoglycemia
Basics
Description
Hypoglycemia results from deficiency of counterregulatory hormones (glucagon, epinephrine, cortisol, growth hormone) or excessive insulin response. Defined as serum glucose <70 mg />L.
Risk Factors
Strict glycemic control with insulin, prior hypoglycemia, hypoglycemia unawareness, impaired counterregulation (<5 years or elderly), renal disease, malnutrition, coronary artery liver congenital metabolic endocrine disorders, hyperinsulinism, and neonatal diabetes mellitus.< />pan>
Etiology
Increased insulin levels due to insulin or oral hypoglycemic overdose, sepsis, insulinoma, autoimmune hypoglycemia, alimentary hyperinsulinism, renal failure, or liver cirrhosis. Decreased glucose production from alcohol use, drugs (salicylates, β-blockers including eye drops, SSRIs, some antibiotics), adrenal insufficiency, malnutrition, dehydration, cerebral edema, extremes of age, heart failure, endocrine disorders, and pregnancy-related substrate deficiency.
Pediatric considerations
Most common cause in first 3 months of life is persistent hyperinsulinemic hypoglycemia of infancy, especially in infants of diabetic mothers.
Diagnosis
Signs And Symptoms Adrenergic symptoms include diaphoresis, anxiety, tachycardia, hunger, paresthesias, chest pain, and ischemic ECG changes. Neuroglycopenic symptoms include dizziness, confusion, behavioral changes, slurred speech, focal deficits, seizures, hemiplegia, coma, and CVA mimic. Neonates may present with poor feeding, irritability, tremors, seizures, or bradycardia.
Alert
Patients with hypoglycemia unawareness may present only with late findings such as seizures or coma.
History
Assess diabetes status, renal or liver disease, alcohol use, medication exposure, and possible overdose.
Physical Exam Findings reflect adrenergic or neuroglycopenic manifestations.
Essential Workup Diagnosis requires neuroglycopenic symptoms, documented low glucose, and symptom resolution after glucose administration.
Diagnosis Tests And Interpretation
Lab Blood glucose (pre- and post-treatment), electrolytes, BUN/creatinine, PT, urinalysis, cultures if infection suspected, C-peptide if exogenous insulin overdose suspected.
Imaging CXR for aspiration or pneumonia if indicated.
ECG Evaluate for ischemia or dysrhythmias.
Differential Diagnosis
Stroke/TIA, seizure, intoxication, hypoxia, sepsis, metabolic or endocrine disorders, psychiatric disease.
Pediatric Growth hormone deficiency, inborn errors of metabolism, ketotic hypoglycemia, Reye syndrome, salicylate ingestion.
Treatment
Prehospital Check finger-stick glucose. Give IV dextrose if possible, oral glucose if awake, or glucagon if IV access unavailable.
Initial Stabilization/Therapy ABCs with seizure and aspiration precautions.
Emergency Department Treatment/Procedures Give D50W 50 mL IV for altered mental status; repeat as needed. Start continuous dextrose infusion (D5–D20) if persistent hypoglycemia or unable to eat. Use octreotide for sulfonylurea-induced or refractory hypoglycemia. Use glucagon if IV access delayed (ineffective in alcohol-related hypoglycemia or severe liver disease). Give hydrocortisone if adrenal insufficiency suspected.
Geriatric considerations Recovery may be prolonged despite correction.
Medications
First Line D50W 25 g IVP (Zimmerman rule: adults 1 mL/kg D50W; children 2 mL/kg D25W; infants 5 mL/kg D10W).
Second Line Octreotide 50 μg IV bolus then infusion or SC dosing; glucagon 0.5–2 mg IV/IM/SC; hydrocortisone 100 mg IV. Oral glucose 20 g if awake and safe.
Follow-Up And Disposition
Admission Criteria Long-acting insulin or sulfonylurea overdose, recurrent hypoglycemia, inability to tolerate oral intake, suicidal intent, persistent neurologic symptoms, or elderly patients with severe episodes.
Discharge Criteria Mild, resolved hypoglycemia with normal glucose, symptom resolution, oral tolerance, and observation for ≥3 hr.
Issues For Referral Primary care follow-up for medication or dietary adjustment.
Follow-Up Recommendations Re-evaluation within 48 hr.
Pearls And Pitfalls
IV dextrose is preferred over oral glucose. Multiple D50 boluses are often required. Do not rely solely on D10/D20. Consider hypoglycemia in all neurologic or psychiatric presentations. Recurrent episodes may require prolonged recovery.
Basics
Description
Hypoglycemia results from deficiency of counterregulatory hormones (glucagon, epinephrine, cortisol, growth hormone) or excessive insulin response. Defined as serum glucose <70 mg />L.
Risk Factors
Strict glycemic control with insulin, prior hypoglycemia, hypoglycemia unawareness, impaired counterregulation (<5 years or elderly), renal disease, malnutrition, coronary artery liver congenital metabolic endocrine disorders, hyperinsulinism, and neonatal diabetes mellitus.< />pan>
Etiology
Increased insulin levels due to insulin or oral hypoglycemic overdose, sepsis, insulinoma, autoimmune hypoglycemia, alimentary hyperinsulinism, renal failure, or liver cirrhosis. Decreased glucose production from alcohol use, drugs (salicylates, β-blockers including eye drops, SSRIs, some antibiotics), adrenal insufficiency, malnutrition, dehydration, cerebral edema, extremes of age, heart failure, endocrine disorders, and pregnancy-related substrate deficiency.
Pediatric considerations
Most common cause in first 3 months of life is persistent hyperinsulinemic hypoglycemia of infancy, especially in infants of diabetic mothers.
Diagnosis
Signs And Symptoms Adrenergic symptoms include diaphoresis, anxiety, tachycardia, hunger, paresthesias, chest pain, and ischemic ECG changes. Neuroglycopenic symptoms include dizziness, confusion, behavioral changes, slurred speech, focal deficits, seizures, hemiplegia, coma, and CVA mimic. Neonates may present with poor feeding, irritability, tremors, seizures, or bradycardia.
Alert
Patients with hypoglycemia unawareness may present only with late findings such as seizures or coma.
History
Assess diabetes status, renal or liver disease, alcohol use, medication exposure, and possible overdose.
Physical Exam Findings reflect adrenergic or neuroglycopenic manifestations.
Essential Workup Diagnosis requires neuroglycopenic symptoms, documented low glucose, and symptom resolution after glucose administration.
Diagnosis Tests And Interpretation
Lab Blood glucose (pre- and post-treatment), electrolytes, BUN/creatinine, PT, urinalysis, cultures if infection suspected, C-peptide if exogenous insulin overdose suspected.
Imaging CXR for aspiration or pneumonia if indicated.
ECG Evaluate for ischemia or dysrhythmias.
Differential Diagnosis
Stroke/TIA, seizure, intoxication, hypoxia, sepsis, metabolic or endocrine disorders, psychiatric disease.
Pediatric Growth hormone deficiency, inborn errors of metabolism, ketotic hypoglycemia, Reye syndrome, salicylate ingestion.
Treatment
Prehospital Check finger-stick glucose. Give IV dextrose if possible, oral glucose if awake, or glucagon if IV access unavailable.
Initial Stabilization/Therapy ABCs with seizure and aspiration precautions.
Emergency Department Treatment/Procedures Give D50W 50 mL IV for altered mental status; repeat as needed. Start continuous dextrose infusion (D5–D20) if persistent hypoglycemia or unable to eat. Use octreotide for sulfonylurea-induced or refractory hypoglycemia. Use glucagon if IV access delayed (ineffective in alcohol-related hypoglycemia or severe liver disease). Give hydrocortisone if adrenal insufficiency suspected.
Geriatric considerations Recovery may be prolonged despite correction.
Medications
First Line D50W 25 g IVP (Zimmerman rule: adults 1 mL/kg D50W; children 2 mL/kg D25W; infants 5 mL/kg D10W).
Second Line Octreotide 50 μg IV bolus then infusion or SC dosing; glucagon 0.5–2 mg IV/IM/SC; hydrocortisone 100 mg IV. Oral glucose 20 g if awake and safe.
Follow-Up And Disposition
Admission Criteria Long-acting insulin or sulfonylurea overdose, recurrent hypoglycemia, inability to tolerate oral intake, suicidal intent, persistent neurologic symptoms, or elderly patients with severe episodes.
Discharge Criteria Mild, resolved hypoglycemia with normal glucose, symptom resolution, oral tolerance, and observation for ≥3 hr.
Issues For Referral Primary care follow-up for medication or dietary adjustment.
Follow-Up Recommendations Re-evaluation within 48 hr.
Pearls And Pitfalls
IV dextrose is preferred over oral glucose. Multiple D50 boluses are often required. Do not rely solely on D10/D20. Consider hypoglycemia in all neurologic or psychiatric presentations. Recurrent episodes may require prolonged recovery.
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