Hypoglycaemia

Question 1

Whipple’s triad - hypoglycaemia

Answer 1

1) Low plasma glucose 3mM
2) Symptoms consistent ̄c hypoglycaemia
3) Relief of symptoms by glucose administration

Question 2

Autonomic symptoms occur at what level? what are the symptoms

Answer 2

2.5-3
Sweating
  Anxiety
  Hunger
  Tremor
Palpitations

Question 3

Neuroglycopenic symptoms occur at what level? what are the symptoms

Answer 3

<2.5
 Confusion
  Drowsiness
  Seizures
  Personality change
  Focal neurology (e.g. CN3)
Coma <2.2

Question 4

Causes of fasting hypoglycaemia: EXPLAIN, in a diabetic vs others

Answer 4

Usually insulin or sulfonylurea Rx in a known diabetic Exercise, missed meal, OD

Exogenous drugs
Pituitary insufficiency
Liver failure
Addison’s
Islet cell tumours (insulinomas)
Immune (insulin receptor Abs: Hodgkin’s)
Non-pancreatic neoplasms: e.g. fibrosarcomas

Question 5

Investigations

Answer 5

72h fast ̄c monitoring

Sympto: Glucose, insulin, C-peptide, ketones

Question 6

Diagnosis if Hyperinsulinaemic hypoglycaemia

Answer 6

Drugs

↑ C-pep: sulfonylureas, Insulinoma

Question 7

Diagnosis if ↓ insulin, no ketones

Answer 7

Non-pancreatic neoplasms Insulin receptor Abs

Question 8

Diagnosis if ↓ insulin, ↑ ketones

Answer 8

Alcohol binge ̄c no food Pituitary insufficiency

Addison’s

Question 9

Insulinoma - path, presentation, investigations, treatment

Answer 9

Path: 95% benign β-cell tumour usually seen ̄c MEN1
Pres: fasting- / exercise-induced hypoglycaemia
Ix:
Hypoglycaemia + ↑ insulin
Ix: Give iv insulin and measure c-peptide. Normally exogenous insulin suppresses c-peptide production, but this does not occur in insulinoma
MRI, EUS pancreas
Rx: excision

Question 10

Post-prandial hypo

Answer 10

Dumping post-gastric bypass

Question 11

Management if alert and orientated and in coeliac

Answer 11

Give Fast acting CHO either:
• 5-7 dextrose tablets OR
• Cold sweet drink e.g. Fruit juice
(150-200mls)
• Original
Lucozade (90-120mls)
(Coeliac - rice krispies)

WAIT 15 mins to re-check BM
1) if less than 4mmol/L -> repeat cycle max 3 times
2) >4mmol/L Give longer acting CHO either:
• Cereal / sandwiches / biscuits
• Next meal if ready
• DO NOT OMIT INSULIN INJECTION IF DUE

Question 12

Management if Drowsy / confused but swallow intact

Answer 12

• Dextrogel® (1.5-2 tubes)
or
• Consider 1mg
+ Glucogon i.m.

WAIT 15 mins to re-check BM
1) if less than 4mmol/L -> repeat cycle max 3 times
2) >4mmol/L Give longer acting CHO either:
• Cereal / sandwiches / biscuits
• Next meal if ready
• DO NOT OMIT INSULIN INJECTION IF DUE

Question 13

Management if Unconscious or Concerned re Swallow but able to secure IV access

Answer 13

• 150ml IV glucose 10%
over 10 -15
minutes
• 75 mls 20%
glucose over 10-15 minutes

Check Bm in 10 mins

Question 14

Management if no access

Answer 14

Immediate glucagon+
injection 1mg I/M

(Won’t work in drunks + short duration of effect (20min). Insulin release may → rebound hypoglycaemia)