WHAT IS THE EMERGENCY MANAGEMENT FOR HYPOGLYCEMIA

Your blood sugar (glucose) level is below the normal range (less than 50 mg/dL) if you have hypoglycemia. Glucose serves as your body's main energy source. Diabetes control and hypoglycemia commonly go hand in hand. However, people without diabetes can experience low blood sugar as a result of a wide range of illnesses and treatments, many of which are unusual.

Etiology: 

Insulin (secreted by the pancreas), counter-regulatory hormones (such as glucagon, catecholamine, and glucocorticoids), and growth hormones interact intricately to maintain glucose homeostasis. Hypoglycemia is often categorized as postprandial (reactive) or fasting.

1. Spontaneous hypoglycemia:

a) Postprandial (reactive) hypoglycemia is characterized by declining glucose levels after a glucose load.

b) Alimentary hypoglycemia occurs in patients who have recently undergone gastrointestinal surgery.

c) Pre-diabetic glucose intolerance: Hypoglycemia may be an early manifestation of non–insulin-dependent diabetes mellitus.

d) Functional (idiopathic) hypoglycemia: Hypoglycemia occurs between the fed and fasting state.

e) Fasting hypoglycemia occurs in patients with significant underlying pathologic conditions.

f) Endogenous insulin excess may result from insulinomas (nonmalignant pancreatic tumors) or extrapancreatic neoplasms.

g) Regulatory hormone deficiencies: Acquired or congenital deficiencies of glucagon, glucocorticoids, or growth hormone can lead to hypoglycemia.

h) Organ failure: Impaired liver or kidney function can lead to hypoglycemia.

Systemic disease: Shock, sepsis, and starvation can cause hypoglycemia.

2. Induced hypoglycemia

a) Insulin-induced hypoglycemia, seen in patients with diabetes, is the most common cause of hypoglycemia seen in the emergency department.

b) Factitious hypoglycemia may be seen in psychiatric patients (e.g., as a result of the ingestion of oral hypoglycemic agents by a patient with Munchausen syndrome).

c) Chemical-induced: Alcohol-induced hypoglycemia is found in malnourished, alcoholic patients. Hypoglycemia can also be brought on by other substances and medicines.

RISK FACTORS: Young children and elderly patients are at high risk for the development of hypoglycemia.

CLINICAL FEATURES are caused by the direct effects of hypoglycemia on the central nervous system as well as its indirect effects on the sympathetic nervous system. Patients may be asymptomatic, or they may present with a wide variety of symptoms.

1. Nonspecific systemic symptoms include dyspnea, hypertension, hyperventilation, sweating, palpitations, peripheral vasodilation, pallor, tachycardia, and tremulousness.

2. Neurologic symptoms include paresthesia, neurologic deficit, diplopia, clonus, and transient hemiplegia.

3.Psychiatric manifestations include impairment of memory, change of personality, combative behavior, fatigue, headache, insomnia, nightmares, visual problems, catatonia, convulsions, and general sluggishness.

DIFFERENTIAL DIAGNOSES: Hypoglycemia may masquerade as a neurologic, psychiatric, or cardiovascular disease. Stroke, diabetic ketoacidosis, nonketotic hyperosmolar coma, alcohol intoxication, alcohol withdrawal, and other causes of coma must all be ruled out.

EVALUATION: Testing for glucose at the bedside is a good method of excluding hypoglycemia.

THERAPY

1. Prehospital providers commonly administer one ampule (25 g) of 50% dextrose intravenously. Alcoholic patients should receive thiamine (100 mg administered intravenously) before receiving dextrose to prevent Wernicke-Korsakoff syndrome. If intravenous access is unavailable, glucagon (0.5 to 2.0 mg) is administered intramuscularly or subcutaneously. The glucagon dose can be repeated twice.

2. After initial treatment, a meal rich in complex carbohydrates should be given. A continuous intravenous infusion of water containing 5% dextrose should be started if the patient is unable to swallow.

DISPOSITION

Admission is indicated for patients who have taken an oral hypoglycemic agent or long-acting insulin. Patients in whom no obvious cause for the hypoglycemia can be identified and patients with persistent neurologic deficits or cardiac complications (e.g., coronary or cerebrovascular insufficiency) should also be admitted.

Discharge: Patients whose symptoms are rapidly reversed without complications and in whom a clear cause for the hypoglycemia has been identified may go home. Patients with diabetes who experience a hypoglycemic episode should be taught how to adjust their insulin dose, food intake, or both based on their level of physical activity.