HYPOGLYCEMIA

Question 1

Whipple’s Triad

Answer 1

(a) Blood glucose measured at <70mg/dl
(b) Clinical signs and symptoms of hypoglycemia (confusion, irritability, fatigue, anxiety, sweating, irregular heart rhythm, perioral paresthesia)
(c) Clinical signs and symptoms resolve with appropriate glucose elevation

Question 2

Symptoms begin at plasma glucose levels in the range of

Answer 2

60 mg/dL and impairment of brain function at approximately 50 mg/dL

Question 3

Spontaneous hypoglycemia in adults is of two principal types:

Answer 3

fasting and postprandial.

Question 4

Fasting hypoglycemia is often

Answer 4

subacute or chronic and usually presents with neuroglycopenia as its principal manifestation.

Question 5

Postprandial hypoglycemia is relatively acute and is often heralded BY

Answer 5

symptoms of neurogenic autonomic discharge (sweating, palpitations, anxiety,
and tremulousness)

Question 6

Signs and Symptoms of a patient with Hypoglycemia

neuroglycopenic

Answer 6

1) As glucose is the main energy source for CNS function, most episodes of symptomatic hypoglycemia include neurologic dysfunction.
2) With a decline in serum sugar, the brain quickly exhausts its reserve supply of carbohydrate fuel, resulting in CNS dysfunction.
3) This manifests most commonly by alterations in consciousness, lethargy, confusion, combativeness, agitation, and unresponsiveness.
4) Other neuroglycopenic manifestations include seizures and focal neurologic deficit

Question 7

Signs and Symptoms of a patient with Hypoglycemia

Sympathomimetic

Answer 7

1) A rapid fall in blood glucose levels or the hypothalamic sensing of neuroglycopenia causes the release of the counter-regulatory hormones, primarily the catecholamines epinephrine and norepinephrine.
a) Typical symptoms include anxiety, nervousness, irritability, nausea,
vomiting, palpitations, and tremor.

Question 8

Lab/imaging findings of a patient with Hypoglycemia

auto-immune

Answer 8

(1) Finger sticks blood glucose (finger stick measurements are technique dependent, most accurate is laboratory measurement)
(2) Serum antibody testing such as GAD-65, anti-islet cell, and anti-insulin antibodies

Question 9

Lab/imaging findings of a patient with Hypoglycemia

surreptitious cause

Answer 9

(1) Finger sticks blood glucose (finger stick measurements are technique dependent,most accurate is laboratory measurement)
(2) Consider C-peptide, serial glucose/insulin levels in supervised setting, serum sulfonylurea levels

Question 10

Differential Diagnosis of a patient with Hypoglycemia

Answer 10

(a) Fasting hypoglycemia
(b) Hyperinsulinism: pancreatic B-cell tumor and accidental or surreptitious insulin or sulfonylurea administration.
(c) Extra-pancreatic tumors
(d) Postprandial hypoglycemia: early hypoglycemia (alimentary)

Question 11

Treatment of a patient with Hypoglycemia

Answer 11

(1) Immediate treatment of hypoglycemia involves provision of glucose.
(2) Patients able to eat or drink can drink juices, sucrose water, or glucose solutions; eat candy or other foods; or chew on glucose tablets when symptoms occur.
(a) Do not attempt PO interventions on a patient with altered mental status- high
aspiration risk.
(3) Adults unable to eat or drink can be given glucagon 0.5 or 1 mg SC/IM or 50%
dextrose 50 to 100 mL IV bolus, with or without a continuous infusion of 5 to
10% dextrose solution sufficient to resolve symptoms.
(4) Once patients are alert and safe to do so, they should consume a meal (containing carbohydrates, proteins, and fats) to prevent immediate hypoglycemia
recurrence

Question 12

Disposition of a patient with Hypoglycemia

Answer 12

(1) Factors that affect the disposition of a hypoglycemic patient are:
(a) Serial determinations of the serum glucose
(b) Both the timing and extent of the response to resuscitative therapy
(c) The need for additional replacement therapy
(d) Comorbidities
(e) The patient’s social situation
(f) Any psychiatric issues
(g) Cause of hypoglycemia
(2) Either continued or recurrent mental status alteration, recurrent hypoglycemia, or a downward trend in serial glucose values during observation despite adequate replacement therapy demands admission to the hospital MEDEVAC.
(3) The case suitable for outpatient observation is characterized by a responsible adult who will monitor the patient’s mental status frequently, coupled with a
motivated patient who will perform serum glucose determinations frequently and who can maintain oral feeding.
(4) Strongly advise early involvement of a medical officer when cause for hypoglycemia is not clearly evident.

Question 13

Complications of a patient with Hypoglycemia

Answer 13

(1) Coma
(2) Brain damage
(3) Traumatic injuries (MVA, falls, etc.)
(4) Death