Hypoglycemia Flashcards
What is the initial test to diagnose hypoglycemia?
Finger prick random HGT if uncertain confirm with a laboratory HGT
List 5 autonomic symptoms of hypoglycemia
Autonomic symptoms
1. Palpitations/Tachycardia
2. Tremors
3. Anxiety
4. Sweating
5. Hunger and fatigue
List 4 neurological symptoms of hypoglycemia
- Confusion(loss attentiveness)
- Convulsions/seizures
- CVA like symptoms(slurred speech and headaches)
- Coma
What glucose level in hypoglycemia do neuro-glycopaenic(4Cs) symptoms occur?
Glucose<2.6 mmol/l
What are the components of the Whipple’s triad?
Used to define hypoglycemia in non-diabetics
1. Symptoms and signs of hypoglycemia
2. Low serum glucose(glucose <3.6 some say 3)
3. Symptoms resolve after administration of glucose
Define Hypoglycemia.in diabetics
Low random glucose(<4 some say 3.9) with/without symptoms
Is there a cut off value for plasma plasma glucose that defines hypoglycemia?
Nope
On what blood glucose levels do.non-diabetics start developing symptoms mostly?
glucose<3.6 mmol/l
List 5 most common causes of hypoglycemia in diabetics
- Insulin/Sulphonylurea overdose
- Alcohol consumption(reduces endogenous production of glucose)
- Missing meals/overnight fasting
- Exercise(Increases insulin sensitivity and cause weight loss)
- Renal failure(Reduces insulin clearance)
State two ways in which exercise triggers hypoglycemia
- Increases glucose usage
- Increases sensitivity of insulin
What is your differential diagnosis of hypoglycemia in a non-diabetic
- EX(Drugs)-Beta blockers, Valproate, Salicylate overdose, quinine and chloroquine, insulin and oral hypoglycemics
- P: hypoPituitarism
- L: Liver disease/failure
- A: Addison’s disease and adrenal crisis
- I: Sepsis from any infection including UTI, pneumonia and meningitis/encephalitis Malaria
- N: Neoplasia such as Insulinoma/Retroperitoneal sarcomas
- Malnutrition: Starvation and Alcohol abuse with malnutrition
- Others: Cardiogenic shock, myxoedema and Anxiety disorder
Define pseudohypoglycemia
Decrease in glucose levels due to laboratory errors such as delayed sample measurements in a setting of erythrocytosis, thrombocytosis or leukocytosis
List three commonest precipitants(NEED TO BE LOOKED FOR) of hypoglycemia
- Liver failure
- Renal failure
- Sepsis
Which medication can lead to hypoglycemia few sympathetic symptoms?
Beta blockers-They blunt the sympathetic symptoms
Is it possible for a diabetic to be desensitized to sympathetic symptoms of hypoglycemia?
Yes it happens in many well controlled diabetics
List 3 commonest drug overdose that leads to hypoglycemia in non-diabetics
- Beta blockers
- Salicylate
- Valproate
Others include quinine, chloroquine, insulin and diabetic meds
Which investigations should be done in all non-diabetics who present with hypoglycemia?
Serum insulin and C peptide to determine the source of hyperinsulinemia.
What does low C peptide and high insulin mean?
Exogenous source
What does high C peptide and high insulin mean?
Endogenous source mostly Insulinoma, sulphonylurea overdose
How long does it take hypoglycemia to cause neurological damage?
4 hours
During the management of hypoglycemia,when do you recheck the glucose levels?
Every 10-15 minutes
You must expect a rapid response to the management within 10-15 minutes
List non-drug immediate management of hypoglycemia
Stabilise ABCs, IV access, check blood glucose, Oxygen if Sats<95%
What is the initial treatment for hypoglycemia in an awake person?
Give glucose 5 ml/kg orally if unable to take orally give glucose or dextrose 10% 5 ml/kg via nasogastric tube(PACK)
Lecture: 50 g dextrose or sugar water(3 teaspoons 15g in 1 cup-200ml water) orally
What is the initial treatment of hypoglycemia if the patient is unconscious/have decreased levels of consciousness?
Lecture:50 ml 50% Dextrose IV
Pack: Dextrose 10% 5 ml/kg (Unavailable mix 1 part of 50% dextrose to 4 parts water to make a dextrose 10% solution)
What is the initial treatment of hypoglycemia if there is no IV access?
Glucagon 1 mg then 50 g dextrose orally when awake
What should be given before dextrose in known alcoholics.who present with hypoglycemia?
Thiamine(Vitamin B1) 100 mg IM/IV(1-2mg/kg)
Also in malnutrition
Who should be referred (patients with hypoglycemia)
1.Incomplete recovery
2. Hypoglycemia without a clear reversible cause
When should a patient be discharged after management of hypoglycemia?
- When they are asymptomatic and off infusion for at least 6 hours depending on the cause
- Cause identified and corrected
- Appropriate follow up has been arranged
State how hypoglycemia without an identifiable cause/unrelated to drugs should be manage further after immediate management.
Start dextrose 5 % infusion 50-100 ml per hour and check glucose 2 hourly
REFER
State how hypoglycemia related to drug overdose/alcoholism is managed further.
- Perform glucose 2 hourly
- Look for coexisting causes
3.Adjust diabetes meds if indicated - Increase concentration of IV fluid if glucose drops again
- REFER IF RECURRENT HYPOGLYCEMIA/A 2NDARY CAUSE IS FOUND
PATIENT MUST EAT
What do you do if glucose is still below 4(diabetics)/3(non-diabetics) after initial management of hypoglycemia i
Dextrose 10% 2 ml/kg IV/NG tube depending on how you were giving it first.
What do you do once the glucose is within the normal range?
Give Dextrose 5% 1L 6 hourly
List 10 conditions to consider in the presence of recurrent hypoglycemia.aftwe management
» inappropriate management, e.g. too much insulin or too high dose of sulphonylurea,
» poor meal adherence,
» poor adherence,
» alcohol abuse,
» physical exercise,
» factitious administration of insulin,
» the “honeymoon” period of type 1 diabetes,
» the advent of renal failure,
» hypoglycaemic unawareness, or
» pancreatic diabetes/malabsorption
Another consideration included Addison’s disease, hypopituitarism and Type 1 diabetic who become unaware.of it.
What is the complication of hypoglycaemic unawareness in diabetic.ans state the antidote?
Severe hypoglycemia can occur
Antidote: avoidance of any hypoglycaemia for at least 2–4 weeks.
Which electrolyte should be checked after management of hypoglycemia?
Serum potassium for hypokalemia
When do you start to consider other causes of coma in the management of hypoglycemia?
30 minutes after normal glucose has been restored and the patient has not regained consciousness
How long should you wait til you discharge a patient who has hypoglycemia due to sulphonylurea overdose?
At least 12 hours after glucose infusion has been stopped.
NOTE: If hypoglycaemia was caused by a sulphonylurea, the patient will require
hospitalisation and a prolonged intravenous glucose infusion.
What is the initial management of hypoglycemia according to the 2019 guidelines?
Dextrose 50% 50 ml IV rapid infusion
Followed by establishing a large bore IV line and keeping it open with dextrose 10% IV
When do you check the blood glucose after administration of the first management of hypoglycemia(2019)?
Recheck within 5-10 minutes new is 10-15 minutes
What do you do if the first dextrose fails to correct hypoglycemia(2019)?
Give Dextrose 50% 50 ml IV
What do you do to prevent recurrence of hypoglycemia after immediate management(2019)?
Dextrose 10% 1 L 6 hourly IV infusion
Outline how hypoglycemia is graded?
Mild/moderate
- Capable of self treatment
- Conscious but requires some help from someone else
Severe
- Unconscious(comatose)/Semi-conscious
- Require medical help
When do patients fail to recognise symptoms of hypoglycemia?(2 instances)
- When they are hypoglycemic unaware especially well controlled diabetics
- When the neuro-glycopaenic (impaired thinking, mood changes, irritability, dizziness, tiredness). start first
If a diabetic patient presents with an altered level of consciousness and a glucometer
is not available, always treat them as what?
Hypoglycemia
Why is thiamine given before.dextrose in hypoglycemic alcoholics?
To prevent neurological damage
Who should be referred after management of hypoglycemia?
» All hypoglycaemic patients on oral hypoglycaemic agents.
» Hypoglycaemic patients who do not recover completely after treatment.
» All children with documented hypoglycaemia unless the cause is clearly identified
and safe management instituted to prevent recurrence.
