This document discusses hypoglycemia, including its causes, clinical features, diagnosis, and treatment. Hypoglycemia is defined as a low blood glucose level below 70 mg/dL that causes symptoms resolved by glucose administration. Common causes in diabetics include inadequate food intake, excessive insulin, and increased exertion. Symptoms include neuroglycopenic effects like confusion and autonomic effects like palpitations. Diagnosis is confirmed with bedside glucose testing. Treatment depends on the patient's consciousness and includes oral carbohydrates, glucagon, or IV glucose. Most patients fully recover within 20 minutes with treatment of the underlying cause and glucose administration.

2. INTRODUCTION
CAUSES
CLINICAL FEATURES
DIAGNOSIS TREATMENT
DISCHARGE

3. INTRODUCTION

4. (1) symptoms consistent with the diagnosis
(2) symptoms associated with a low glucose level,
usually <50 mg/dL (<2.7 mmol/L)
(3) symptoms resolve with glucose administration
It is clinically defined as follows:
WHIPPLE
TRIAD

5. • Normal :70-99mg/dL , PP: 140mg/dL
• Plasma glucose is normally maintained
at 3.6-5.8mmol/L
• Cognitive deteriorates at levels
<3.0mmol/L
• Symptoms are uncommon >2.5mmol/L

6. FACTS

7. Human brain depends on glucose as its
primary source of energy
It is unable to synthesize or store glucose
(accounting for the common manifestation of
hypoglycemia as altered mental status)

8. Physiologic response to low blood glucose
suppression of insulin secretion
release of the counter-regulatory
hormones

9. Renal clearance of insulin decreases with
age, and this may enhance the risk of
hypoglycemia in the elderly.

10. CAUSES

11. In diabetics, the commonest cause is a
relative imbalance of administered versus
required insulin/OHA

12. Common scenarios in diabetics:
- inadequate/delayed food intake
- excessive insulin administration
- increased physical exertion
- change in drug therapy
- drug interactions
- sudden reduction in diet
- renal failure

13. Other causes are:
• Alcohol
• Addison’s disease
• Pituitary insufficiency
• Post gastric surgery
• Liver failure
• Malaria
• Insulinomas
• Extra-pancreatic tumors
• Attempted suicide/homicide (with large doses of
insulin/OHAs)

14. CLINICAL
FEATURES

15. Neuroglycopenic Autonomic
Lethargy
Confusion
Agitation
Seizures
Combativeness
Unresponsiveness
Focal neurologic deficits
Alterations in consciousness
Anxiety
Nervousness
Irritability
Nausea
Vomiting
Palpitations
Tremor

17. Medical conditions that can be
mistaken for hypoglycemia
• Stroke
• Transient ischemic attack
• Seizure disorder
• Traumatic head injury
• Brain tumor
• Narcolepsy
• Multiple sclerosis
• Psychosis
• Sympathomimetic drug
ingestion
• Hysteria
• Altered sleep patterns and
nightmares
• Depression

18. DIAGNOSIS

19. The diagnosis can
easily be confirmed
using bedside glucose
testing

20. Hypoglycemia should always be considered
early as there is a potential cause of
altered mental status

21. Can mimic any neurological presentations:
coma seizures
acute confusion
isolated hemiparesis

22. Failure to determine the blood glucose level early in the
evaluation can result in a delayed or missed diagnosis
with associated morbidity because of CNS injury or
unnecessary invasive procedures and therapies.

23. TREATMENT

24. Depends on conscious state and
degree of cooperation of patient

25. 1) 5-15g fast acting oral carbohydrate
(eg: Lucozade, sugar lumps, Dextrosol, followed by biscuits & milk)

26. 2) Glucagon 1mg: SC, IM or IV
– Can be administered by relatives or ambulance crew if difficult
venous access.
– Response to this is slower than IV dextrose, need 7-10min until
normal mental status
– Will not work with alcoholics, elderly & depleted glycogen store

27. 3) Glucose 10% solution 50ml IV
repeated at 1-2min interval until patient fully conscious
4) Glucose 50% solution
hypertonic & no more effective than glucose 10%
(if used, give into large vein & follow with saline flush)
5) Octreotide (synthetic analog of somatostatin)
– Inhibit release of insulin
– Used in treatment of sulfonylurea-induced hypoglycaemia
– Only consider if doesn’t respond to dextrose

28. WARNING!
• Suggest underlying pathology (stroke),
development of cerebral edema due to
hypoglycaemia (high mortality)
• Maintain plasma glucose at 7-11mmol/L
• Contact ICU & consider mannitol or
dexamethasone
• CT scan
Persistence of an altered conscious level

29. DISCHARGE

30. 20 minutes
90% patient fully recover in

31. When hypoglycemic cause is identified &
fully corrected, patient can be discharged
after observation at ED & appropriate
follow up.

32. Arrange follow up having considered the following:
Why did this episode occur?
Has there been any recent change of regimen,
other drugs, alcohol, etc?
Is the patient developing hypoglycemic
unawareness or autonomic dysfunction?

33. References
• Tintinalli’s Emergency Medicine, A Comprehensive
Study Guide, 6th edition, McGraw Hill publication.
• Oxford Handbook of Emergency Medicine, 4th
edition, Oxford university press publisher.

34. THANK YOU
Prepared by Nur Hanisah Zainoren

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