|Initial Management Summary: CBG = Capillary blood glucose|
- Trembling, sweaty, confused, hungry, anxiety, coma, seizure
- If GCS <9 and does not respond quickly or difficult to manage get help
- Hypoglycaemia: CBG <4 (technically 3 mmol/L). Coma when CBG < 1.5 mmol/L
- Conscious:4 glucotabs or Dextrogel or 15-20 g sugar snack. Not diet drinks
- Unconscious/unable to take oral glucose:
- 150 mls of 10% glucose IV or
- Glucagon 1 mg IM stat (not in malnourished or liver failure)
- Persisting hypoglycaemia: 1 L 10% Glucose over 4-6 hrs
- Review cause +/- diabetes management
The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus 4th edition Revised January 2020 Link here
- Potentially fatal or else a cause of brain damage if delayed treatment
The chief cause is insulin or sulfonylurea treatment
in a diabetic, eg missed meal, accidental or non-accidental overdose
- Diabetic: Sulphonylureas, Insulin, GLP-1 analogues, Glitazones
- Acute alcohol, Liver failure, Addison's disease, Malaria, Quinine treatment
- Insulinoma, Critical illnesses, Pituitary failure, Body builders on Insulin
- Malnutrition/fasting uncommon cause of acute hypoglycaemia
- Metformin does not cause hypoglycaemia
- Autonomic: Sweating, Palpitations, Hunger
- Neuroglycopenia: Confusion, Drowsiness, Odd behaviour, Speech difficulty, Incoordination
- General malaise: Nausea, headache
- Eventually: coma, hemiparesis, seizures, death
- A sign may be: Seizure, Stroke, Delirium, New Neurology, Fall in GCS, unexplained fall
Unlikely causes of hypopglycaemia: alcohol, eg a
binge with no food; aspirin poisoning; ACE-i; Beta blockers; pentamidine; quinine sulfate, aminoglutethamide; insulin-like growth factor
- Stroke, delirium, coma, seizure
- Investigate and Send laboratory sample
- No detectable C-peptide—only released with endogenous insulin
- Symptoms or signs of hypoglycemia +
- Low plasma glucose
- Resolution of symptoms or signs post glucose rise.
- Measurement: Blood (Finger stix) < 3-4 mmol/L (72 mg/dl). Confirm reading by sending laboratory sample. Review diabetes therapy. If suspicious consider measuring C peptide if exogenous insulin considered at fault.
- Oral Glucose cooperative patient: Able to swallow: 15-20g quick-acting carbohydrate e.g. Sugary (Non-diet) 150-200 ml of pure fruit juice, 4 heaped teaspoons of sugar dissolved in water. Give 2 biscuits or 250 ml of Cow's Milk. Repeat CBG 10-15 minutes later. And if CBG < 4.0mmol/L repeat step but if this fails 3 times get medical help
- Oral Glucose Uncooperative patient: If uncooperative but can swallow give 2 tubes 40% glucose gel (e.g. Glucogel) squeezed into the mouth between the teeth and gums else move to Glucagon.
- Unable to take oral glucose then Glucagon 1mg IM (less effective if taking sulphonylurea). Can take 15 mins to take effect. It mobilises glycogen from the liver. Less effective in the chronically malnourished (e.g. alcoholics), or after prolonged starvation with depleted glycogen stores or with severe liver disease. Give IV glucose if no response.
- IV Glucose: give 150 ml of 10% glucose (over 10-15 minutes) or equivalent of 20% or 50% until symptoms treated. Repeat CBG 10 minutes later. If it is still less than 4.0 mmol/L, repeat dose.
- Prolonged Hypoglycaemia state consider ongoing 10% glucose infusion. Repeat CBG measurement regularly and continue glucose and oral carbohydrate whilst looking for the cause (refer to Appendix 4 for administration details)
- Pabrinex (Thiamine) If suspected alcoholic or malnourished give Pabrinex along with glucose
- After treating review diabetes management and dietary intake to try to prevent a recurrence
- Investigating: 72h fasting may be needed (monitor closely). Bloods: glucose, insulin, C-peptide, and plasma ketones if symptomatic