Hypoglycaemia (Blood glucose under 4.0 mmol/l) is potentially fatal and should be treated. it may be defined as “mild” self-treated, or “severe” treated by a third party i.e. you.
Hypoglycaemia is a common side-effect of insulin and sulfonylureas (they start with gli-) as they both work by lowering glucose concentration in the blood. Other diabetic medications work by preventing glucose rise, thus posing a lesser risk.
Signs & Symps
- Autonomic: Sweating, Palpitations, Shaking, Hunger
- Neuroglycopenic: Confusion, Drowsy, Odd behaviour, Incoordination, Speech difficulty
- General: Nausea, Headache
Risk Factors
- Medical:
- Diabetic: Strict control, Long term Insulin, Lipohypertrophy at injection sites,Impaired awareness of hypoglycaemia
- Organ dysfunction: Severe hepatic dysfunction, Renal impairment, Cognitive dysfunction/dementia, Endocrine (Addisons, hypothyroid, hypopituitary)
- GIT: Gastroenteritis, impaired absorption, Bariatric surgery
- Medication: Concurrent use of medicines with hypoglycaemic agents e.g. warfarin, quinine, salicylates, fibrates, sulphonamides (including cotrimoxazole), monoamine oxidase inhibitors, NSAIDs, probenecid, somatostatin analogues, SSRIs.
- Sepsis
- Terminal illness
- Lifestyle:
- Reduced/Irregular intake: Poor diet, Irregular lifestyle, Alcohol
- Increased use: Exercise (relative to usual), Early pregnancy, Breast feeding
- Poor control: Increasing age, No or inadequate blood glucose monitoring, Alcohol
Treatment
Conscious & Orientated
- 15-20g fast acting glucose
- 4-5 jelly babies
- 3-4 heaped teaspoons of sugar dissolved in water (milk delays absorption)
- 150-200ml fresh fruit juice
- Rpt Blood Glucose 10-15min
- if blood glucose remains <4.0mmol/l step one may be repeated up to 3 times in total
- Blood Glucose remains <4.0mmol/l
- 150-200ml 10% Glucose IV
- 1mg Glucogon IM (if starved or sulfonylureas may not work well)
- Blood Glucose >4.0mmol/l – Give long acting Carbs
- 2 Biscuits
- 1 Slice bread/toast
- 200-300ml milk (not soya)
- Meal
- Don’t omit insulin injections
- Diabetic review: most patients can be followed up by diabetic nurses but some may need admission.
- Patient Advice Sheet
Conscious but agitated, confused, unable to cooperate
- If patient CAN cooperate – follow guide above
- If patient CAN’T cooperate
- 1.5 -2 tubes 40% glucose gel (Glucogel) squeezed into the mouth between the teeth and gums (can be substituted for step 1 above)
- 1mg Glucogon IM (if starved or sulfonylureas may not work well)
- Follow subsequent steps as above
Unconscious, seizures, very aggressive
Start at step 3 above (while managing ABC), the choice of whether to use IV glucose or IM glycogen will be determined by practicality of achieving IV/IO access.
Although you will need to follow the remaining steps the patient will almost certainly require admission.
Reference
Patient Advice Sheet – Hypo’s
Joint British Diabetic Society – The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus 3rd edition
