Hypoglycaemia

Question 1

What is the definition of hypoglycaemia?

Answer 1

• Blood glucose 3mmol/L or less
• Context dependent, if patient is symptomatic at around 4mmol/L its probably wise to treat
• ‘4 is the floor’

Question 2

Which diabetes is a hypo more common in?

Answer 2

Type 1

Type 2 in the elderly and in renal impairment, or if treated with insulin and sulfonylureas

Question 3

What symptoms occur in hypoglycaemia?

Answer 3

Autonomic - Sweating, anxiety, tremor, hunger, palpitations, dizziness
Neuroglycopenic - Confusion, drowsiness, visual trouble, seizures, coma, transient hemiplegia

Question 4

What are some potential causes of hypoglycaemia?

Answer 4

• Insulin or sulfonylurea treatment
• Increased activity
• Missed meal
• Accidental or non accidental overdose

Question 5

What are some potential causes of hypoglycaemia in a non diabetic? (EXPLAIN)

Answer 5

Ex - Exogenous drugs - insulin, oral hypoglycaemics, alcohol, aspirin poisoning, ACEi, Betablockers
P - Pituitary insufficiency
L - Liver failure
A - Addisons disease
I - Islet cell tumours (insulinomas), immune hypoglycaemia
N - Non pancreatic neoplasms eg fibrosarcomas

Question 6

What investigations would you do?

Answer 6

Bloods - 
- Glucose, insulin, c-peptide, plasma ketones
- LFT'S - Exclude liver failure
- May need to do 72hr fasting
Urinalysis
- Glucose and ketones

Question 7

What is the immediate management in hypoglycaemia in a patient who is conscious, oriented and able to swallow?

Answer 7

• Fast acting CHO eg glucojuice, cold sweet drink, 5-7 glucose tablets
• Measure after 15 minutes and repeat cycle up to 3 times if needed
• If no response, treat as unconscious hypoglycaemia

Question 8

What is the immediate management in hypoglycaemia in a patient who is conscious and able to swallow, but is confused?

Answer 8

• Treat as mild if cooperative
• If uncooperative, 1.5-2 tubes of glucose gel squeezed into mouth
• Measure after 15 minutes and repeat cycle up to 3 times if needed

Question 9

What is the immediate management in hypoglycaemia in a patient who is unconscious/aggressive/NMB?

Answer 9

1. Check ABCDE
2. Stop IV insulin and secure IV access
3. Administer 75ml 20% glucose over 10-15 minutes (using braun pump, set pump at 300mls/hr stopped after 15 minutes)
4. If no IV access, adminster glucagon IM
5. Recheck capillary blood glucose after 10 mins. If below 4mmol/L repeat IV glucose or consider glucose infusion of 50ml/hr.

Question 10

What is the dose for IM glucagon?

Answer 10

1mg

Can only be given once

Question 11

When do you start IV insulin after hypoglycaemia?

Answer 11

When CBG >4mmol/L

Question 12

What do you give a patient when their blood glucose recovers?

Answer 12

A long acting carbohydrate eg a slice of toast

Question 13

What does hypoglycaemic hyperinsulinaemia mean as to the cause of hypoglycaemia?

Answer 13

• Insulinoma
• Sulfonylurea/insulin injection
• Congenital HH

Question 14

What does low insulin and no ketones in the blood mean as to the cause of hypoglycaemia?

Answer 14

• Non pancreatic neoplasm

- Anti insulin receptor antibodies

Question 15

What does decreased insulin and increased ketones in the blood mean as to the cause of hypoglycaemia?

Answer 15

• Alcohol
• Pituitary insufficiency
• Addison’s disease

Question 16

What is post prandial hypoglycaemia?

What investigation would you do?

Answer 16

• Low blood glucose after a meal ‘dumping syndrome’
• May occur after gastric/bariatric surgery
• Do prolonged OGTT