Metabolic / Endocrine
Hypoglycemia is the most common and severe complication in diabetic patients:
- 30-40% of patients with T1DM each year.
- 10-30% with T2DM each year.
- without treatment can lead to cardiovascular events, seizures, brain damage and death.
Most patients can be discharged, except in cases of long-acting antidiabetic medication usage or neuroglycopenia unresponsive to carbohydrate administration.
Diagnosis of Hypoglycemia
1. Signs or symptoms consistent with hypoglycemia (autonomic or neuroglycopenic symptoms):
- Neurogenic (autonomic) – trembling, palpitations, sweating, anxiety, hunger, nausea, paresthesias.
- Neuroglycopenic – poor concentration, confusion, weakness, drowsiness, vision changes, headache, dizziness, speech difficulties.
2. Blood Glucose (BG) < 4 mmol/L in diabetic patients receiving insulin/insulin secretagogue therapy OR BG < 3 mmol/L in spontaneous hypoglycemia.
3. Resolution of symptoms after raising plasma glucose level.
- Mild: Autonomic symptoms of hypoglycemia are present; patient is able to self-treat.
- Moderate: Both autonomic and neuroglycopenic symptoms are present; patient is able to self-treat.
- Severe: Patient requires assistance to correct BG and may have loss of consciousness. BG typically < 2.8 mmol/L.
Treatment in Patient with Diabetes
15 g carbohydrate PO, ideally as glucose or sucrose tablets/solution. In those with diabetes, BG should be measured 15 minutes after administration2. Second dose if BG remains <4.0 mmol/L.
Conscious: 20 g carbohydrate PO, ideally as glucose tablet or equivalent. In 15 minutes, additional 15 g glucose PO if BG remains <4.0 mmol/L.
Unconscious: 10-25 g glucose (20-50 mL D50W) IV over 1-3 minutes. In pediatric patients, this is lowered to 0.5 to 1 g/kg.
- If IV unavailable, 1 mg glucagon SC/IM increases BG within 60 minutes. Effectiveness reduced with alcohol consumption, fasting, or advanced hepatic disease.
- Thiamine administration should not delay glucose supplementation.
Once the hypoglycemia is reversed, if next meal is > 1 hour, 15g carbohydrate and a protein source should be consumed.
In sulfonylurea overdose and refractory hypoglycemia, octreotide has been shown to increase BG and reduce recurrent hypoglycemia. Following dosages are generally recommended:
- IV: 50 µg bolus and infusion of 25 µg/h (1 µg/kg/h in peds).
- SC: 50-100 µg in adults (1-2 µg/kg in peds) every 6-12 hours.
Treatment in Patient without Diabetes
Treatment follows the same protocol for glucose administration as in diabetic hypoglycemia.
Hypoglycemia in non-diabetic patients is a red flag.
Whenever suspected to be secondary cause, blood should be drawn prior to administration of glucose. For diagnostic purposes, this sample should include:
- Blood glucose.
- β-hydroxybutyrate concentration.
- Screen for oral hypoglycemic agents and insulin antibodies.
- Blood Alcohol Content.
- Oral hypoglemic agents:
- Metformin when used with sulfonylureas.
- SGLT2 inhibitors (i.e. dapagliflozin and empagliflozin).
- Sulfonylureas (i.e. Glyburide).
- Thiazolidinediones (i.e. Actos and Avandia).
- MAO inhibitors.
- Sulfamethoxazole – trimethoprim (Septra).
2. Concurrent illnesses.
3. Exogenous hyperinsulinism – an oral hypoglycemic agent that may not be reported in history (i.e. malicious administration).
4. Endogenous hyperinsulinism is rare:
- Noninsulinoma pancreatogenous hypoglycemia syndrome.
- Post-gastric bypass hypoglycemia.
- Insulin autoimmunity.
- Long-acting antidiabetic agents (non-short acting insulins, sulfonylureas, meglitinides).
- Neuroglycopenia that does not rapidly resolve.
- Fever without an obvious source in poorly controlled diabetics.
- Resolution of neuroglycopenia.
- New-onset diabetics who do not meet the mentioned criteria for admission, and do not have metabolic decompensation.
- Follow-up with their primary care provider within 24-48 hours for education, dietary evaluation and discussion of treatment.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Treatment of hypoglycemia – Quality of evidence is low. Based on formal consensus.
Addition of thiamine – Quality of evidence is low. Based on a series of case reports.
Addition of octreotide – Quality of evidence is low. Based on a series of case reports, a small RCT and a small crossover study.
Tintinalli, J. E., Ma, O. J., Yealy, D. M., Meckler, G. D., Stapczynski, J. S., Cline, D., & Thomas, S. J. (2016). Tintinallis emergency medicine: a comprehensive study guide (8th Ed). New York: McGraw Hill Education.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 20, 2021
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