๐Ÿฉบ Hypoglycemia

Review 2025

เธ เธฒเธงเธฐเธ™เน‰เธณเธ•เธฒเธฅเธ•เนˆเธณ - Emergency Medical Review

Source: Medsharecape

๐Ÿ“‹ Overview

Hypoglycemia = Blood glucose < 70 mg/dL

  • Common emergency in medical settings
  • Rapid deterioration from inadequate cellular nutrition
  • Often caused by Insulin or Sepsis
  • Nurses/EMTs can initiate treatment in many institutions

๐Ÿงฌ Physiology of Hypoglycemia

Hormone Balance

โฌ‡๏ธ Lowers Glucose

  • Insulin

โฌ†๏ธ Raises Glucose

  • Glucagon
  • Epinephrine
  • Norepinephrine
  • Cortisol
  • Growth hormone

These are Counterregulatory hormones

๐Ÿง  Response to Low Glucose

Organ Response
Pancreas โ†“ Insulin, โ†‘ Glucagon
Brain Activates Sympathetic NS โ†’ Epinephrine, Norepinephrine
Pituitary โ†‘ Growth hormone, โ†‘ Cortisol
Liver Glycogenolysis + Gluconeogenesis

โš ๏ธ Liver disease โ†’ Higher hypoglycemia risk

โš ๏ธ HAAF

Hypoglycemia-Associated Autonomic Failure

  • Beta cell failure in severe diabetes
  • Insulin doesn't decrease, Glucagon doesn't increase
  • Repeated hypoglycemia โ†’ body becomes "desensitized"
  • Hypoglycemia unawareness โ€” no warning symptoms!
  • Patient goes straight to severe symptoms (confusion, seizures)

๐Ÿฅ Clinical Manifestation

Autonomic Symptoms

(Early warning)

  • Palpitations ๐Ÿ’“
  • Sweating ๐Ÿ’ฆ
  • Hypertension
  • Tremor
  • Hunger

Neuroglycopenic Symptoms

(Brain glucose deprivation)

  • Confusion ๐Ÿ˜ต
  • Seizures โšก
  • Fatigue
  • Behavioral changes
  • Hemiparesis (stroke-like)

๐Ÿ”บ Whipple Triad

Allen Whipple, 1938

  1. Symptoms consistent with hypoglycemia
  2. Low blood glucose
    • DM patients: < 70 mg/dL
    • Non-DM: < 55 mg/dL
  3. Resolution of symptoms when glucose rises

๐Ÿ“Š Severity Classification

Level Symptoms Action
Mild None or minimal (palpitations, sweating) Oral glucose
Moderate Neuroglycopenic (fatigue, weakness) Oral/IV glucose
Severe Altered consciousness, seizures IV glucose/Glucagon STAT

๐Ÿ” Etiology

Common Causes

  • Insulin / Insulin secretagogues (most common)
  • Decreased glucose intake
  • Increased glucose utilization (exercise)
  • Increased insulin sensitivity
  • Alcohol (hepatotoxic)
  • Renal failure (reduced insulin clearance)

More Causes

  • Critical illness / Sepsis
  • Hormone deficiencies (Addison's, Hypopituitarism)
  • Insulinoma
  • Glycogen storage disease
  • Post gastric bypass (Dumping syndrome)

๐Ÿงช Diagnostic Workup

When cause is unclear, check during hypoglycemia:

Test Purpose
Plasma glucoseConfirm hypoglycemia
InsulinElevated in insulinoma
C-peptideโ†“ in exogenous insulin
Proinsulinโ†“ in exogenous insulin
Beta-hydroxybutyrateโ†“ with insulin/IGF
Oral hypoglycemic agentsScreen for sulfonylurea
Insulin antibodiesAutoimmune syndrome

๐Ÿ”ฌ Key Differentials

Exogenous Insulin

  • Most common cause in DM patients
  • Low C-peptide & Proinsulin (not in injected insulin)
  • Low Beta-hydroxybutyrate (insulin inhibits ketogenesis)

Insulinoma

  • Beta cell tumor producing excess insulin
  • 90% benign, 10% malignant
  • Associated with MEN1
  • High C-peptide & Proinsulin
  • Diagnosis: CT (70-80%), MRI (85%), EUS (>90%)

Post Gastric Bypass

  • Food enters small intestine rapidly
  • Rapid glucose spike โ†’ excessive insulin release
  • GLP-1 and GIP amplify insulin response
  • Timeline: Hyperglycemia at 30 min โ†’ Hypoglycemia at 2 hrs
  • Treatment: Small, frequent meals

๐Ÿ’Š Management in DM

JBDS-IP Guideline

  1. ABCDE assessment
  2. Stop IV insulin immediately
  3. Treat based on patient status

๐ŸŸข Conscious & Can Swallow

Give 15-20g fast-acting carbs:

  • Orange juice 200ml
  • 3-4 teaspoons sugar water
  • Glucose tablets

Recheck CBG in 10-15 minutes

Can repeat 1-2 times if needed

๐Ÿ”ด Unconscious / Seizing / NPO

  • IV Glucose: 20-25g (50% Glucose 50ml)
  • OR Glucagon: 1mg IM (if no IV access)

Recheck CBG in 10-15 minutes

โš ๏ธ Glucagon may fail in severe DM or liver disease

After Recovery (>70 mg/dL)

  • If can eat: Long-acting carb snack (20g)
    • 1 slice bread
    • 2 biscuits
  • If NPO: 10% Glucose 100ml/hr
  • โš ๏ธ Don't completely stop scheduled insulin โ€” adjust dose

๐Ÿ›ก๏ธ Prevention

Recurrent Hypoglycemia

  • Oral meds: Switch away from Insulin secretagogues
  • Insulin:
    • More frequent glucose monitoring
    • Consider GLP-1 agonists
    • Switch Human insulin โ†’ Insulin analogs
    • Use Basal-bolus regimen

๐Ÿ’‰ Insulin Types

Human Insulin (Problems)

Type Issue
Regular insulin Lasts ~6hrs, overlaps with next meal โ†’ hypoglycemia
NPH Peaks at ~6hrs โ†’ nocturnal hypoglycemia

Insulin Analogs (Better)

Type Examples Benefit
Rapid-acting Aspart, Lispro Fast onset, short duration
Long-acting Glargine, Detemir Peak-less, stable levels

โœ… More physiologic, less hypoglycemia risk

๐Ÿ“ Key Takeaways

  • Recognize early: Autonomic symptoms (sweating, palpitations)
  • Confirm: Whipple Triad
  • Treat fast: Oral glucose if conscious, IV/Glucagon if not
  • Investigate: C-peptide distinguishes exogenous vs endogenous insulin
  • Prevent: Insulin analogs + proper regimen

๐Ÿ“š References

  • Harrison's Principles of Internal Medicine, 21st ed
  • William's Textbook of Endocrinology, 14th ed
  • Guyton & Hall Textbook of Medical Physiology, 14th ed
  • ADA Standards of Care in Diabetes, 2024
  • JBDS-IP Guideline, 2023
  • Thai Clinical Practice Guideline for Diabetes, 2023

๐Ÿ™ Thank You

Questions?

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