Hypoglycemia

Question 1

What is the initial test to diagnose hypoglycemia?

Answer 1

Finger prick random HGT if uncertain confirm with a laboratory HGT

Question 2

List 5 autonomic symptoms of hypoglycemia

Answer 2

Autonomic symptoms
1. Palpitations/Tachycardia
2. Tremors
3. Anxiety
4. Sweating
5. Hunger and fatigue

Question 3

List 4 neurological symptoms of hypoglycemia

Answer 3

1. Confusion(loss attentiveness)
2. Convulsions/seizures
3. CVA like symptoms(slurred speech and headaches)
4. Coma

Question 4

What glucose level in hypoglycemia do neuro-glycopaenic(4Cs) symptoms occur?

Answer 4

Glucose<2.6 mmol/l

Question 5

What are the components of the Whipple’s triad?

Answer 5

Used to define hypoglycemia in non-diabetics
1. Symptoms and signs of hypoglycemia
2. Low serum glucose(glucose <3.6 some say 3)
3. Symptoms resolve after administration of glucose

Question 6

Define Hypoglycemia.in diabetics

Answer 6

Low random glucose(<4 some say 3.9) with/without symptoms

Question 8

Is there a cut off value for plasma plasma glucose that defines hypoglycemia?

Answer 8

Nope

Question 9

On what blood glucose levels do.non-diabetics start developing symptoms mostly?

Answer 9

glucose<3.6 mmol/l

Question 10

List 5 most common causes of hypoglycemia in diabetics

Answer 10

1. Insulin/Sulphonylurea overdose
2. Alcohol consumption(reduces endogenous production of glucose)
3. Missing meals/overnight fasting
4. Exercise(Increases insulin sensitivity and cause weight loss)
5. Renal failure(Reduces insulin clearance)

Question 11

State two ways in which exercise triggers hypoglycemia

Answer 11

1. Increases glucose usage
2. Increases sensitivity of insulin

Question 12

What is your differential diagnosis of hypoglycemia in a non-diabetic

Answer 12

1. EX(Drugs)-Beta blockers, Valproate, Salicylate overdose, quinine and chloroquine, insulin and oral hypoglycemics
2. P: hypoPituitarism
3. L: Liver disease/failure
4. A: Addison’s disease and adrenal crisis
5. I: Sepsis from any infection including UTI, pneumonia and meningitis/encephalitis Malaria
6. N: Neoplasia such as Insulinoma/Retroperitoneal sarcomas
7. Malnutrition: Starvation and Alcohol abuse with malnutrition
8. Others: Cardiogenic shock, myxoedema and Anxiety disorder

Question 13

Define pseudohypoglycemia

Answer 13

Decrease in glucose levels due to laboratory errors such as delayed sample measurements in a setting of erythrocytosis, thrombocytosis or leukocytosis

Question 14

List three commonest precipitants(NEED TO BE LOOKED FOR) of hypoglycemia

Answer 14

1. Liver failure
2. Renal failure
3. Sepsis

Question 15

Which medication can lead to hypoglycemia few sympathetic symptoms?

Answer 15

Beta blockers-They blunt the sympathetic symptoms

Question 16

Is it possible for a diabetic to be desensitized to sympathetic symptoms of hypoglycemia?

Answer 16

Yes it happens in many well controlled diabetics

Question 17

List 3 commonest drug overdose that leads to hypoglycemia in non-diabetics

Answer 17

1. Beta blockers
2. Salicylate
3. Valproate

Others include quinine, chloroquine, insulin and diabetic meds

Question 18

Which investigations should be done in all non-diabetics who present with hypoglycemia?

Answer 18

Serum insulin and C peptide to determine the source of hyperinsulinemia.

Question 19

What does low C peptide and high insulin mean?

Answer 19

Exogenous source

Question 20

What does high C peptide and high insulin mean?

Answer 20

Endogenous source mostly Insulinoma, sulphonylurea overdose

Question 21

How long does it take hypoglycemia to cause neurological damage?

Answer 21

4 hours

Question 22

During the management of hypoglycemia,when do you recheck the glucose levels?

Answer 22

Every 10-15 minutes

You must expect a rapid response to the management within 10-15 minutes

Question 23

List non-drug immediate management of hypoglycemia

Answer 23

Stabilise ABCs, IV access, check blood glucose, Oxygen if Sats<95%

Question 24

What is the initial treatment for hypoglycemia in an awake person?

Answer 24

Give glucose 5 ml/kg orally if unable to take orally give glucose or dextrose 10% 5 ml/kg via nasogastric tube(PACK)

Lecture: 50 g dextrose or sugar water(3 teaspoons 15g in 1 cup-200ml water) orally

Question 25

What is the initial treatment of hypoglycemia if the patient is unconscious/have decreased levels of consciousness?

Answer 25

Lecture:50 ml 50% Dextrose IV Pack: Dextrose 10% 5 ml/kg (Unavailable mix 1 part of 50% dextrose to 4 parts water to make a dextrose 10% solution)

Question 26

What is the initial treatment of hypoglycemia if there is no IV access?

Answer 26

Glucagon 1 mg then 50 g dextrose orally when awake

Question 27

What should be given before dextrose in known alcoholics.who present with hypoglycemia?

Answer 27

Thiamine(Vitamin B1) 100 mg IM/IV(1-2mg/kg) Also in malnutrition

Question 29

Who should be referred (patients with hypoglycemia)

Answer 29

1.Incomplete recovery 2. Hypoglycemia without a clear reversible cause

Question 30

When should a patient be discharged after management of hypoglycemia?

Answer 30

1. When they are asymptomatic and off infusion for at least 6 hours depending on the cause 2. Cause identified and corrected 3. Appropriate follow up has been arranged

Question 31

State how hypoglycemia without an identifiable cause/unrelated to drugs should be manage further after immediate management.

Answer 31

Start dextrose 5 % infusion 50-100 ml per hour and check glucose 2 hourly REFER

Question 32

State how hypoglycemia related to drug overdose/alcoholism is managed further.

Answer 32

1. Perform glucose 2 hourly 2. Look for coexisting causes 3.Adjust diabetes meds if indicated 4. Increase concentration of IV fluid if glucose drops again 5. REFER IF RECURRENT HYPOGLYCEMIA/A 2NDARY CAUSE IS FOUND PATIENT MUST EAT

Question 33

What do you do if glucose is still below 4(diabetics)/3(non-diabetics) after initial management of hypoglycemia i

Answer 33

Dextrose 10% 2 ml/kg IV/NG tube depending on how you were giving it first.

Question 34

What do you do once the glucose is within the normal range?

Answer 34

Give Dextrose 5% 1L 6 hourly

Question 36

List 10 conditions to consider in the presence of recurrent hypoglycemia.aftwe management

Answer 36

» inappropriate management, e.g. too much insulin or too high dose of sulphonylurea, » poor meal adherence, » poor adherence, » alcohol abuse, » physical exercise, » factitious administration of insulin, » the “honeymoon” period of type 1 diabetes, » the advent of renal failure, » hypoglycaemic unawareness, or » pancreatic diabetes/malabsorption Another consideration included Addison's disease, hypopituitarism and Type 1 diabetic who become unaware.of it.

Question 37

What is the complication of hypoglycaemic unawareness in diabetic.ans state the antidote?

Answer 37

Severe hypoglycemia can occur Antidote: avoidance of any hypoglycaemia for at least 2–4 weeks.

Question 38

Which electrolyte should be checked after management of hypoglycemia?

Answer 38

Serum potassium for hypokalemia

Question 39

When do you start to consider other causes of coma in the management of hypoglycemia?

Answer 39

30 minutes after normal glucose has been restored and the patient has not regained consciousness

Question 40

How long should you wait til you discharge a patient who has hypoglycemia due to sulphonylurea overdose?

Answer 40

At least 12 hours after glucose infusion has been stopped. NOTE: If hypoglycaemia was caused by a sulphonylurea, the patient will require hospitalisation and a prolonged intravenous glucose infusion.

Question 41

What is the initial management of hypoglycemia according to the 2019 guidelines?

Answer 41

Dextrose 50% 50 ml IV rapid infusion Followed by establishing a large bore IV line and keeping it open with dextrose 10% IV

Question 42

When do you check the blood glucose after administration of the first management of hypoglycemia(2019)?

Answer 42

Recheck within 5-10 minutes new is 10-15 minutes

Question 43

What do you do if the first dextrose fails to correct hypoglycemia(2019)?

Answer 43

Give Dextrose 50% 50 ml IV

Question 44

What do you do to prevent recurrence of hypoglycemia after immediate management(2019)?

Answer 44

Dextrose 10% 1 L 6 hourly IV infusion

Question 45

Outline how hypoglycemia is graded?

Answer 45

Mild/moderate - Capable of self treatment - Conscious but requires some help from someone else Severe - Unconscious(comatose)/Semi-conscious - Require medical help

Question 46

When do patients fail to recognise symptoms of hypoglycemia?(2 instances)

Answer 46

1. When they are hypoglycemic unaware especially well controlled diabetics 2. When the neuro-glycopaenic (impaired thinking, mood changes, irritability, dizziness, tiredness). start first

Question 47

If a diabetic patient presents with an altered level of consciousness and a glucometer is not available, always treat them as what?

Answer 47

Hypoglycemia

Question 48

Why is thiamine given before.dextrose in hypoglycemic alcoholics?

Answer 48

To prevent neurological damage

Question 49

Who should be referred after management of hypoglycemia?

Answer 49

» All hypoglycaemic patients on oral hypoglycaemic agents. » Hypoglycaemic patients who do not recover completely after treatment. » All children with documented hypoglycaemia unless the cause is clearly identified and safe management instituted to prevent recurrence.