4. (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:
WHIPPL
E
5. • 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
7. 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)
8. Physiologic response to low blood
glucose
suppression of insulin secretion
release of the counter-
regulatory hormones
9. Renal clearance of insulin decreases
with age, and this may enhance the
risk of hypoglycemia in the elderly.
11. In diabetics, the commonest cause is
a relative imbalance of administered
versus required insulin/OHA
12. Common scenarios in
diabetics:
- inadequate/delayed food
intake
- excessive insulin
administration
- increased physical exertion
- change in drug therapy
- drug interactions
- sudden reduction in diet
13. 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)
21. Can mimic any neurological
presentations:
com
a
seizur
es
acute confusion
isolated
22. 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
25. 1) 5-15g fast acting oral
carbohydrate
(eg: Lucozade, sugar lumps, Dextrosol, followed by biscuits
& milk)
26. 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
27. 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
28. WARNING!
Persistence of an altered
conscious level
• 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
31. When hypoglycemic cause is
identified & fully corrected, patient
can be discharged after observation
at ED & appropriate follow up.
32. 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?
33. Referenc
es
• Tintinalli’s Emergency Medicine, A
Comprehensive Study Guide, 6th edition,
McGraw Hill publication.
• Oxford Handbook of Emergency Medicine,
4th edition, Oxford university press
publisher.
