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Hypoglycaemia (Aetiology (Metabolic Renal/liver failure, Endocrine …
Hypoglycaemia
Aetiology
Metabolic
Renal/liver failure
Endocrine
Hypoglycaemic unawareness
Long duration DM
Pituitary insufficiency
Addison's disease
Neoplastic
Islet cell tumour
Fibrosarcoma
Drugs
Inappropriate insulin use
Oral hypoglycaemics e.g. sulphonylureas
Alcohol
Others e.g. aspirin, B-blockers, ACEi
Idiopathic
Food/drink mismatch
Exercise
Hot weather
Iatrogenic
Post gastric/bariatric surgery
Infection
Pneumonia
Severe sepsis
Functional/psych
Factitious hypoglycaemia
Pathophysiology
Low glucose levels stimulates SNS, causing SNS symptoms
Reduced glucose supply to major organs - brain first to show signs
Longstanding insulin-tx DM and freq hypos reduces hypo awareness; risk major hypos where 3rd party help needed
Multiple causes, can be due to underlying DM (iatrogenic hypo) or triggered by a pathological process (reactive hypo)
Diagnosis
Examination
General - pallor, sweating
Cardio - tachycardic
Neuro - reduced GCS, tremor, seizures
Investigations
Bloods
FBC (infection), CRP (infection),
U+E (renal fail), LFTs (liver fail)
Glucose - low
Insulin - high if insulinoma or drugs
C-peptide - high if endogenous insulin e.g. insulinoma
Ketones - low (non-panc cancer, T1DM), high
(alcohol, Addisons, pituitary insiffuciency)
Special tests
OGTT
ACTH stimulation test (Addison's)
Bedside
Obs - tachy, infection signs
ECG - tachy
BM - low glucose
Imaging
CT abdo - if suspected insulinoma
Urine
Glucose, ketones
History
HPC: onset, symptoms, red flags
PMH: DM, previous hypos/hospitalisations,
hypo awareness
DH: hypo drugs, insulin, compliance, allergies
FH: DM, other endocrine, cancer
SH: meals, alcohol, smoking, exercise
Glycaemic awareness
(GOLD scoring)
'Do you know when hypos happening?'
Score 1 (always) to 7 (never)
Definitions
Biochemical disorder of
low blood glucose (<4mmol/L)
Clinical disorder of Whipple's triad:
1) Low plasma glucose
2) Hypo symptoms
3) Resolution of symptoms with hypo correction
Clinical
presentation
Neurological
Visual disturbance
Seizures
Confusion, reduced conciousness
Coma
Focal neuro signs
(rare)
Systemic
Tremor
Palpitations
Anxiety
Syncope
Sweating
Nausea
Headache
Management
Initial ABCDE
Definitive
Conservative
Glucose monitoring 15-20min
Identify cause
No driving >45min
Review meds, charts and BM diary
If severe needing 3rd party, inform DVLA
Medical
PO sugar
Indication: conscious patient
E.g. dextrose tabs, Cola, sweets
IV glucose
Indication: unconscious with IV access,
or no response to initial tx
E.g. 50% glucose 25-50mL
NB, saline flush to prev phlebitis
IM glucagon
Indication: unconscious, no IV access
MOA: increases glucose release from cells
E.g. 1mg IM glucagon
CI: sulfonylurea induced hypo
Long-acting carbs
Indication: asap once revived
E.g. toast, fruit, digestive biscuits
MOA: prevent recurrence
Referral
Freq, unpredictable hypos
Nocturnal hypos
Impaired hypo awareness
Epidemiology
Commonest endocrine
emergency