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INTRODUCTION
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
Lethargy
Confusion
Agitation
Seizures
Combativeness
Unresponsiveness
Focal neurologic deficits
Alterations in consciousness
Anxiety
Nervousness
Irritability
Nausea
Vomiting
Palpitations
Tremor
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 seizures
acute 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 minutes
90% 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 YOU
Prepared by Nur Hanisah Zainoren
Follow me on
slideshare.com
for a lot of helpful
yet interesting
slides
“hanisahwarrior”

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Hypoglycemia

  • 1.
  • 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: WHIPPLE TRIAD
  • 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 - renal failure
  • 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)
  • 15. Neuroglycopenic Autonomic Lethargy Confusion Agitation Seizures Combativeness Unresponsiveness Focal neurologic deficits Alterations in consciousness Anxiety Nervousness Irritability Nausea Vomiting Palpitations Tremor
  • 16.
  • 17. 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
  • 19. The diagnosis can easily be confirmed using bedside glucose testing
  • 20. Hypoglycemia should always be considered early as there is a potential cause of altered mental status
  • 21. Can mimic any neurological presentations: coma seizures acute confusion isolated hemiparesis
  • 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 and therapies.
  • 24. Depends on conscious state and degree of cooperation of patient
  • 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! • 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
  • 30. 20 minutes 90% patient fully recover in
  • 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. 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.
  • 34. THANK YOU Prepared by Nur Hanisah Zainoren
  • 35. Follow me on slideshare.com for a lot of helpful yet interesting slides “hanisahwarrior”

Editor's Notes

  1. *Choose appropriate option from following:
  2. Lucozade – glucose tablets