Diabetic Emergencies - Hypoglycaemia

Question 1

What level of glucose is defined as hypoglycaemia in diabetic patients?

Answer 1

< 3.5 mmol/l (< 4 in hospital inpatients)

Question 2

Describe the 3 stages of hypoglycaemia

Answer 2

1) Mild symptomatic - person recognises the hypo and is able to treat themselves
2) Asymptomatic - doesn’t feel it but does a finger prick and sees they are hypoglycaemic
3) Severe diabetes emergency - defined as an episode in which the person is unable to treat themselves bc of cognitive incapacity (confusion) induced by hypoglycaemia

Question 3

Why does hypoglycaemia occur?

Answer 3

• Hypoglycaemia is a side effect of treatment to lower blood glucose by increasing insulin levels
• Mismatch between insulin levels in body and insulin requirements
• The excess insulin leads to suppressed glucose and ketone production by the liver and existing glucose is diverted to muscle and fat

Question 4

Why is hypoglycaemia a problem?

Answer 4

• The brain is dependent on blood glucose (or ketones) as a fuel source as it has no energy stores and can’t use alternate energy stores
• So in hypoglycaemia there is no energy supply for the brain

Question 5

What happens in normal people when they have low glucose?

Answer 5

Increased ketones

Question 6

What are the autonomic symptoms of hypoglycaemia?

Answer 6

• Activation of ANS
• Sweating
• Tremor
• Palpitations

Question 7

What are the neuroglycopenic symptoms of hypoglycaemia (due to brain being low on glucose)?

Answer 7

• Confusion
• Drowsiness
• Speech, behaviour and visual disturbance
• Incoordination
• Circumoral paraesthesiae

Question 8

What are other symptoms of hypoglycaemia?

Answer 8

• Hunger
• Headache
• Nausea

Question 9

What happens in hypoglycaemia counter-regulation in a normal person?

Answer 9

• Because the brain energy source is so important, there are a lot of protective mechanisms
• Blood glucose should not hit 3 if the mechanisms are working

Question 10

What happens in hypoglycaemia counter-regulation in people with T1D?

Answer 10

• The first two lines of defence against hypoglycaemia are gone in T1D on insulin (suppression of insulin secretion and glucagon release)
• Therefore the first symptoms of hypoglycaemia for people with T1D are hunger and autonomic symptoms (important they act quickly bc not much time before brain dysfunction)

Question 11

What happens in people with T1D and hypoglycaemia unawareness?

Answer 11

The trigger point for autonomic symptoms falls so the first symptoms of hypoglycaemia are brain dysfunction (increased risk of severe hypoglycaemia)

Question 12

How do you treat mild hypoglycaemia?

Answer 12

1) Check capillary blood glucose (< 3.5)
2) If conscious and able to swallow safely give oral fast-acting carbohydrate 15-20g
3) Wait 10 mins and recheck - if still hypoglycaemic repeat and re check in 5-10 minutes

Question 13

What are some examples of 15-20g of oral fast-acting carbohydrates?

Answer 13

• Lucozade/fruit juice 150-200ml
• Dextrose tablets x 5
• Jelly beans (10-15)/jelly babies (4-5)

Question 14

How do you treat severe hypoglycaemia when the patient is unconscious/not able to swallow safely?

Answer 14

• Call for help
• ABCDE
• Check capillary blood glucose
• If possible IV glucose e.g. glucose 20% 75-100ml
• If no IV access/out of hospital glucagon 1mg s/c or IM
• Wait 10 mins and recheck, if still hypoglycaemic repeat (minus glucagon) and recheck in 5-10min

Question 15

Why can you only give glucagon once in 24h to treat hypoglycaemia?

Answer 15

Bc have released all glycogen supply from the liver, if given once won’t work again

Question 16

How do you treat severe hypoglycaemia if the patient is conscious and able to swallow safely?

Answer 16

• Check CBG if possible, if not possible assume hypoglycaemic
• Treat as for mild hypoglycaemia if possible
• Otherwise try glucogel 2 tubes (squeeze between teeth and inner cheek)
• Otherwise treat as for unconscious
• Wait 10 mins and recheck, if still hypoglycaemic repeat and recheck in 5-10min

Question 17

How to you treat when the hypoglycaemia has recovered (> 3.5/4)?

Answer 17

1) Eat 15-20g long-acting/complex carbohydrate e.g. 2 biscuits, one slice of bread
2) Do not omit insulin injection if due (might have to reduce dose)
3) Find out the cause of the hypoglycaemia

Question 18

What are causes of hypoglycaemia?

Answer 18

1) Too much insulin/sulphonylurea
2) More exercise
3) Less carbohydrate
4) Less stress
5) Change in medication e.g. stopping steroids - steroids increase glucose so if stop it, can cause hypoglycaemia
6) Renal failure/liver failure/early pregnancy (first few weeks more sensitive to insulin, can become hypoglycaemic)

Question 19

In late pregnancy are you more or less resistant to insulin?

Answer 19

More resistant