Rosen & Barkin's 5-Minute Emergency Medicine Consult (378 page)

• Diagnosis with finger stick glucose
  
• IV dextrose preferred
  
• Oral glucose–containing fluids in awake patient if unable to obtain IV
  
• Glucagon if unable to give IV glucose or oral glucose
  

• ABCs with aspiration and seizure precautions
  
• Glucose:
  
  • Dextrose IV push (IVP)—this should always be given if possible.
    
  • Oral glucose in awake patient (with no IV) without risk of aspiration
    
  • Glucagon IM if unable to establish IV access
    

• Administer D
  ₅₀
  W 50 mL for decreased level of consciousness:
  
  • 2nd or 3rd amp may be necessary.
    
  • Complications include volume overload and hypokalemia.
    
• Administer octreotide:
  
  • If hypoglycemia refractory to glucose administration
    
  • If hypoglycemia secondary to sulfonylureas
    
  • Initiate continuous IV infusion of 5–20% glucose solution for persistent mild hypoglycemia or if patient cannot eat.
    
• Administer glucagon:
  
  • If hypoglycemia refractory to glucose
    
  • If IV access delayed
    
  • Ineffective in alcohol-induced hypoglycemia and significant liver disease
    
  • May repeat twice q20–30min
    
  • Administer hydrocortisone with glucagon for adrenal insufficiency.
    
  • Effective in 10–20 min
    

Elderly patients often have less hypoglycemic awareness and require significant time for resolution of symptoms, even after appropriate treatment of hypoglycemia.

• D
  ₅₀
  W: 1–2 amps (25 g) of 50% dextrose IVP
  
  • Zimmerman rule of 50: Adult 1 mL/kg of D
    ₅₀
    W; child: 2 mL/kg D
    ₂₅
    W; infants: 5 mL/kg D
    ₁₀
    W)
    

• Octreotide: 50 μg IV bolus then 50 μg IV/hr drip or 50 μg q12hSC/IV
  
• Glucagon: 0.5–2 mg IV/IM/SC:
  
  • Child: 0.03–0.1 mg/kg IV/IM/SC
    
  • Infant: 0.3 mg/kg IV/IM/SC
    
  • May repeat in 4 hr
    
• Hydrocortisone: 100 mg (peds: 1–2 mg/kg) IV
  
• Oral glucose: 20 g orally equals ∼12 oz nondiet fruit juice, 14 oz nondiet cola
  
  • Carbohydrate without fat or protein preferred
    

FOLLOW-UP

• Overdose of long-acting oral hypoglycemic agent (e.g., sulfonylureas) or long-acting insulin mandate observation for at least 24 hr.
  
• Failure of neuroglycopenic symptoms to improve with glucose administration suggests neurologic injury, pre-existing neurologic condition, or another cause for these symptoms.
  
• Recurrent hypoglycemic state in ED
  
• Patients unable to tolerate oral fluids or food
  
• Suicidal intentions
  
• Older patients may require several days for complete recovery from severe or prolonged hypoglycemia.
  

• Discharge mild unintentional insulin overusage or failure to take oral calories if blood glucose normal, symptoms resolved, tolerating oral intake, and can be observed.
  
• Families of patient with recurrent hypoglycemia should be instructed in IM glucagon administration.
  
• Monitor blood glucose for at least 3 hr prior to discharge.
  

Refer to primary physician for consideration of medication or diet changes if recurrent hypoglycemic episodes.

PMD follow-up for medication re-evaluation within 48 hr

• Administration of PO glucose or food may initially further decrease glucose level; therefore, IV dextrose always preferred if possible
  
• Multiple amps of D
  ₅₀
  W commonly required
  
• Do not over rely on D10/D20 as even these concentrations contain relatively small amounts of glucose.
  
• Hypoglycemia should be in the differential for all neurologic and psychiatric presentations.
  
• Recurrent hypoglycemia patients often require hours to days for full neurologic recovery
  

• McCall AL. Insulin therapy and hypoglycemia.
  Endocniol Metab Clin North Am.
  2012;41(1):57–87.
  
• Service FJ. Hypoglycemia.
  Med Clin North Am
  . 1995;79(1):1–8.
  
• Stanley CA, Baker L. The causes of neonatal hypoglycemia.
  N Engl J Med
  . 1999;340:1200–1201.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Altered
  
• Mental
  
• Status
  

CODES

• 251.1 Other specified hypoglycemia
  
• 251.2 Hypoglycemia, unspecified
  
• 775.1 Neonatal diabetes mellitus
  

BASICS

• Oral or parenteral agents that may cause hypoglycemia or other metabolic imbalances
  
• Hypoglycemic poisoning may be intentional or unintentional (accidental)
  

• Insulin:
  
  • Enhances glucose uptake into cells
    
  • Limits glucose availability to the brain (most sensitive to hypoglycemia)
    
  • Influences potassium redistribution (hypokalemia)
    
• Sulfonylurea and Meglitinide agents:
  
  • Enhance insulin release from pancreatic β cells, reduce hepatic glucose production, and increase peripheral insulin sensitivity
    
  • Hypoglycemic effect enhanced by:
    
    • Polypharmacy (drug interactions)
      
    • Alcohol use and hepatic dysfunction (poor nutritional stores)
      
    • Renal insufficiency (decreased clearance)
      
• GLP1 modulators:
  
  • Exenatide is an analog of glucagon-like peptide 1 (GLP1)
    
  • Gliptins (sitagliptin and saxagliptin) inhibit DDP4 which normally inactivates GLP1
    
  • Net effects: Enhanced insulin secretion, delayed gastric emptying, and increased satiety
    
  • Unclear effects on glucose metabolism in overdose (data are lacking at this time)
    
• Biguanide agents (metformin):
  
  • Antihyperglycemic agents:
    
    • Decrease elevated serum glucose concentrations
      
    • Generally do not cause hypoglycemia in isolation.
      
  • In the presence of insulin, biguanides do the following:
    
    • Increase glucose uptake into cells
      
    • Limit glucose availability to the brain (most sensitive to hypoglycemia)
      
    • Influence potassium redistribution (hypokalemia)
      
    • Decrease GI glucose absorption
      
    • Decrease hepatic gluconeogenesis
      
    • Metabolize glucose to lactate in intestinal cells, which may accumulate and lead to profound lactic acidosis
      
• Thiazolidinediones:
  
  • In the presence of insulin, thiazolidinediones increase glucose uptake and use and decrease gluconeogenesis
    
• α-glucosidase inhibitors:
  
  • Lower systemic glucose by decreasing GI absorption of carbohydrates
    

DIAGNOSIS

• Insulin or sulfonylureas:
  
  • Overdose causes hypoglycemia
    
  • Symptoms most often occur when glucose <40–60 mg/dL (may occur at higher levels in diabetics)
    
  • Symptoms blunted by β-antagonists
    
  • Facial flushing, diaphoresis, pallor, piloerection
    
  • Hunger, nausea, abdominal cramping
    
  • Labored respirations, apnea
    
  • Headache, blurred vision
    
  • Paresthesias, weakness, incoordination, tremor
    
  • Anxiety, irritability, bizarre behavior, confusion, stupor, coma, seizures
    
  • Palpitations, tachycardia, bradycardia (late)
    
  • Hypertension
    
  • Hypothermia
    
• Biguanides:
  
  • Toxicity primarily owing to lactic acid accumulation
    
  • Nausea, vomiting, abdominal pain
    
  • Agitation, confusion, lethargy, coma
    
  • Kussmaul respirations
    
  • Hypotension, tachycardia