Hypoglycemia Flashcards
What is the presentation of hypoglycemia?
Autonomic Response (first, approx 3.0mmol)
- Hunger
- Tachycardia
- Diaphoresis
- Anxiety
- Palpitations
- Tremulousness
- Dry mouth
- Pallor
Neuroglycopenic Symptoms (later)
- Headache
- Drowsiness, Confusion, cognitive dysfunction
- Giddiness
- Weakness, fatigue
- Behavioural changes
- Blurred vision, diplopia
- Ataxia
- Seizures (before going into coma)
- And finally unconsciousness / coma
What are the investigations to be performed for hypoglycemia?
Main investigation: CBG
- Hypoglycaemia if CBG < 4mmol/L
- If borderline hypoglycaemia: Should always check CBG again due to 10% variability in reading
ADDITIONAL Investigations 🡪 if suspecting 2’ cause of Hypoglycaemia (i.e. when 2 attempts to orally correct blood glucose fails)
Biochemistry
- 72 hour fast (to deplete normal reserves): test plasma glucose, C peptide (only present in endogenous insulin production), Insulin (reference interval <3 mU/L)
- Toxicology screen: sulfonylureas
- BoHB Levels: marker of hepatic reserve; in hyperinsulin state, will be normal or raised
- Plasma glucose post glucagon challenge
- IGF 1 levels
- Insulin Ab levels
- Short Synacthen Test if hypocortisolism is suspected
- Rule out liver and renal failure
Imaging
- CT/MRI imaging
- EUS
- Octreotide scintigraphy
- 18F DOPA PET scan
- GLP1 receptor imaging
- Arterial stimulation Venous sampling (ASVS)
What is the management of mild hypoglycemia outside of the hospital?
1) First provide 15g of sugar
- 3 Sweets
- Half a can of soft drink (not sugar free version)
2) Monitor for 15 minutes, then CBG again 🡪 assess for response
3a) If responsive & sufficient 🡪 bring forward next meal of Complex Carbs (b/c on-board insulin is still working) + correct underlying cause of hypoglycaemia
3b) If responsive & insufficient 🡪 give 15g again and wait 15min
3c) If non-responsive 🡪 give 15g again and wait 15min
- If responsive 🡪 3a
- If still unresponsive 🡪 AMBULANCE and workup for secondary causes
Corticosteroids may also be required if there is a possibility of pituitary or adrenal dysfunction
What is the management of conscious hypoglycemia within the hospital?
First provide 15g of sugar
- Provide 15g of glucose drink
- Followed by snack w/ at least 15g of complex carbs
- Check CBG in 15 min
Hourly CBG for 4 hours after rescue from Hypoglycaemia
What is the management of hypoglycemia with impaired consciousness outside of the hospital?
Can put honey or strawberry jam under the tongue
Or Glucagon IM injection if family is trained
What is the management of hypoglycemia with impaired consciousness within the hospital?
Firstly, rescue patient from neuroglycopenic status
- If IV access is available – IV 40ml 50% Dextrose as a slow IV push + saline flush
- If IV access is NOT available – 0.5-1mg IM / SC Glucagon
Then correct hypoglycaemia
- Provide Glucose Infusion (D5%, 1.5L / day)
- If consciousness is regained 🡪 feed patient a meal
- Recheck CBG every 15min until euglycaemia is attained 🡪 then recheck CBG 1H for 4 hours
What is Whipple’s triad?
- Classical Symptoms and Signs of Hypoglycaemia
- Low plasma glucose concentration <4 (DM) or <2.8 (non-DM)
- Immediate resolution of symptoms with reversal of low glucose
What are the causes of hypoglycemia?
[Diabetic]
Usually iatrogenic
- Overdose/insulin-mealtime mismatch/wrong method of insulin adminstration
- Poor oral intake/ appetite
- Increased exercise/body metabolism
- Decreased renal/hepatic function and clearance of medications/insulin
- Development of hypocortisolism
[Non-Diabetic]
- Insulinoma
- Hypocortisolism
- GH deficiency
- Severe hepatic, renal, cardiac failure
- Alcohol
- Sepsis (including malaria)
How to counteract exercise induced hypoglycemia?
Cutting down the insulin 🡪 easier option, esp for unplanned exercise; cut down by 20% and adjust subsequently based on patient’s experience
Eating more before exercise
What is the classification of hypoglycemia?
- documented symptomatic hypoglycemia (symptoms present, CBG <3.9)
- severe hypoglycemia (requires 3rd party assistance)
- asymptomatic hypoglycemia (symptoms absent, CBG < 3.9)
- probably symptomatic hypoglycemia (symptoms present, CBG not measured)
- relative hypoglycemia (symptoms present, CBG >3.9)
