Hypoglycaemia Flashcards
Diabetic Emergency
What is the most common side effect of insulin therapy?
Hypoglycaemia
Name three factors that can precipitate a hypoglycemic episode
(1) Irregular eating habits
(2) Unusual exertion
(3) Alcohol excess
When are the times of greatest risk for hypoglycemia?
Before meals, during the night, and during or after exercise
What is the glucose threshold for Level 1 hypoglycemia?
3.9 mmol/L (70 mg/dL) or less
At what glucose level is hypoglycemia considered clinically serious (Level 2)?
<3.0 mmol/L (<54 mg/dL)
What defines Level 3 (severe) hypoglycemia?
Severe cognitive impairment requiring external assistance for recovery.
What are three autonomic symptoms of hypoglycemia?
Sweating, tremor, and palpitations
What are three neuroglycopenic symptoms of hypoglycemia?
Confusion, cognitive impairment, and coma
Why can beta-blockers make hypoglycemia harder to detect?
They mask adrenergic symptoms like tremor and palpitations but not sweating
What tool can be used to assess hypoglycemia awareness?
The Gold score or Clarke score
Why is delayed symptom recognition (<3.0 mmol/L) concerning?
It significantly increases the risk of severe hypoglycemia
At what blood glucose level should hypoglycemia always be treated?
<4.0 mmol/L
When should the DVLA be informed regarding hypoglycemia?
After one or more severe hypoglycemic episodes requiring hospital admission
How much oral glucose should be given for mild hypoglycemia?
15-20g of fast-acting glucose
eg, full-sugar juice
Why are chocolate bars or biscuits not recommended for treating hypoglycemia?
Their fat content slows glucose absorption
How is severe hypoglycemia (confusion or coma) managed?
IM glucagon
(common outside healthcare settings) or IV glucose in the hospital
What should be done after initial glucose administration?
Retest blood glucose after 15 minutes and repeat treatment if needed
How many times per day is it recommended that people with poorly controlled type 1 diabetes check their finger-prick blood glucose levels (without showing improvements in control) before they would be considered suitable for the use of CGMS (continuous glucose monitoring
8-10 times per day
What is the name given to the neurological features of hypoglycaemia
e.g. confusion, blurred vision, behaviour change, or seizures?
Neuroglycopenia
What level of blood glucose do the DVLA recommend before driving a car?
Blood glucose of 5mmol/l or greater (‘5 to drive’)
What level of blood glucose is generally taken to indicate hypoglycaemia?
A blood glucose level of 3.5 mmol/l or lower is generally regarded as the cut off for hypoglycaemia
Who should be able to administer IM Glucagon to a person with symptomatic hypoglycaemia who is not able to treat themselves?
Close friends and relatives of people with insulin-treated type 1 diabetes should be trained to do this
What is the first line treatment for management of hypoglycaemia in a fully conscious patient?
10-20g of fast acting oral carbohydrate
A 40-year-old female is admitted to the hospital following a seizure. Her past medical history includes multiple non-fatal overdoses using her elderly mother’s insulin. Her capillary glucose returns at 3.4mmol/L (normal range 3.5-5.5 mmol/L)
What test would be the most useful in differentiating an endogenous from an exogenous cause of her hypoglycaemia?
Serum C-peptide
A 63-year-old diabetic man is admitted to the hospital to have intravenous antibiotics for community-acquired pneumonia. On day 3 of admission, he becomes confused and drowsy after which he has a short seizure which spontaneously resolves. His capillary glucose is noted at 3.1mmol/L (normal 3.5-5.5 mmol/L) and he is unconscious
What is the most appropriate immediate management of this patient?
Intravenous glucose
A 28-year-old female with type 1 diabetes experiences confusion, fatigue and aggressive behaviour following a long cycle ride. Her husband checks her fingerprick blood glucose and finds that she has a level of 3.0 mmol/l (normal range 3.5-5.5 mmol/L). She is drowsy and not willing to eat or drink anything. She cannot manage to treat herself.
What is the correct approach to treating her hypoglycaemia in this situation by her husband?
IM Glucagon injection
A 33-year-old female reports feeling generally unwell with fatigue, headaches, double vision and intermittent blackouts. She has been found on the latest occasion to have a random blood glucose of 2.2 mmol/L (normal range 3.5-5.5 mmol/L). She feels better when eating foods high in sugar.
It is suspected that she has an insulinoma. What is the best test for establishing the diagnosis?
A 72 hour fast
An 18-year-old female patient with known type 1 diabetes was admitted 4 days previously with DKA. She has been switched to her normal subcutaneous insulin and was due for discharge following diabetic team review. A nurse has taken her blood sugar (9:00 am) before breakfast and informs you that her blood glucose is 2.5, she has no symptoms. The patient is alert.
What would be the next appropriate step?
Glucogel
A 52-year-old man with Type 2 Diabetes on anti-hyperglycaemic drugs including Metformin has a hypoglycaemic event with a capillary blood glucose of 2.4 recorded on the ward.
Which medication is most likely the cause?
Sulphonylureas
= Gliclazide
A 40-year-old male is on the general medical ward when he begins to feel tremulous. He has been admitted for hyperglycemia and was diagnosed with type 2 diabetes, for which he has started medication. A blood sugar is 3.3 mmol/L (3.5 - 5.5 mmol/L). On examination, he is alert, but sweaty, and feels nauseous.
What is the next step in his management?
Oral Glucogel
What is the management of patients with mild hypoglycaemia who are still conscious to restore normal glucose levels?
(1) Eat/drink 15-20g fast acting carbohydrate such as glucose tablets, a small can of Coca-Cola, sweets or fruit juice.
(2) AVOID chocolate
(3) Eat some slower acting carbohydrate afterwards (e.g. toast)
What is the first line treatment in an alert patient with hypoglycaemia?
A sugary beverage or GlucoGel orally (aiming 15 - 20g simple carbohydrate), followed by a carbohydrate-rich meal
What do you do for patients who are unconscious or unable to swallow in those with severe hypoglycaemia?
(1) Take an A-E approach and consider if airway protection is required
(2) Administer 100ml of 20% glucose or 200ml of 10% glucose intravenously
(3) In patients with no IV access, give 1mg of glucagon intramuscularly
A 21-year-old woman presents to the emergency department. She has recently been diagnosed with type 1 diabetes mellitus and has accidentally given herself too much quick-acting insulin (40 units as opposed to her usual 4 units). She is panicked and cannot remember the name of the insulin that she takes. She is feeling lightheaded and generally weak. On examination, her GCS is 15, she is anxious but co-operative and sweating. Her blood glucose is 2.9 on a finger-prick test.
What is the best next step in the management of this patient? and why?
Oral glucose
= Oral glucose is a first-line treatment in patients who are co-operative and can swallow. This can take the form of dextrose tablets, glucose drinks or fruit juice with the aim of giving 15–20 g of a quick-acting carbohydrate
With the Glasgow coma score, when is oral glucose used?
GCS 15 (Fully alert)
✅ Oral glucose can be safely given
GCS 14-13 (Mild confusion, but following commands)
⚠️ Use caution—oral glucose may be considered if the patient can swallow safely
GCS ≤12 (Drowsy, unresponsive, not protecting airway)
❌ Oral glucose is NOT safe. Use IV glucose or IM glucagon
A 35-year-old woman with type 1 diabetes feels dizzy and shaky while shopping. She checks her blood glucose, which is 3.0 mmol/L. She is alert, oriented, and speaking normally. What is the most appropriate next step?
A) IV 10% dextrose
B) IM glucagon
C) Oral glucose (e.g., glucose tablets or juice)
D) IV 50% dextrose
E) Observe without intervention
c - Oral glucose
High insulin, Low C-peptide =
Exogenous insulin administration
A 55-year-old man is brought to the emergency department by his colleagues due to confusion, unsteadiness, and slurred speech. On examination, he is disoriented, with a noticeable smell of alcohol on his breath. His vital signs include a blood pressure of 130/80 mmHg and a heart rate of 88 bpm. His colleagues are unsure about any of his past medical history.
What is the best next immediate step?
Measure capillary blood glucose
A 19-year-old man presents to the Emergency Department (ED) in the early hours of the morning looking very confused. The on-call doctor tries to take a history from the man however he has trouble speaking. He is unable to walk in a straight line and keeps bumping into other people in the ED. His girlfriend who has accompanied him informs the doctor that he recently contracted malaria for which he was taking quinine sulfate
What is the most appropriate first-line investigation for this man and why is this the case?
Blood glucose measurement
= Hypoglycaemia is commonly mistaken for being ‘drunk’, and so blood glucose measurement should always be part of the initial assessment
