Presentation
Autonomic Response:
Catecholaminergic/adrenergic mediated:
Nervousness/anxiety
tachycardia
palpitations
Tremors
Acetylcholinergic/cholinergic mediated:
diaphoresis
Hunger
Paresthesias
Neuroglycopenic symptoms:
Confusion
behavioral changes
dizzy/weakness
seizures
transient focal neurologic deficits
loss of consciousness
visual disturbances
How low is low?
Moderate 40-70mg/dL
Severe <40mg/dL
Differential diagnosis:
Medications
Insulin
sulfonylureas
Alcohol
Beta-blockers
Acetaminophen overdose
Systemic illness
Sepsis
myxedema coma
Myocardial infarction
hepatic disease
adrenal insufficiencies
Other
Lab error
Leukemia, erythrocytosis, hemolytic disease
post-surgical: Gastric bypass
Anorexia nervosa
Work-up
point-of-care / fingerstick glucose
can be artificially elevated by maltose (patients receiving IVIG or peritoneal dialysate)
may be inaccurate in patients with poor perfusion
chemistries
hepatic panel
TSH
Beta-hydroxybutyrate
EKG, Troponin when indicated
infectious work-up when indicated: CBC, CXR, UA, blood cultures
ethanol levels
Inpatient workup
insulin, C-peptide level, pro-insulin level, glucagon, growth hormone, cortisol, insulin antibodies
Management
IV dextrose bolus
D50W ampules
1 ampule = 50mL of D50W = 25g glucose
Serum glucose concentrations increase approximately 4-6 mg/dL per gram of dextrose administered
serum glucose levels rise approximately 100-150mg/dL per ampule of D50W
This is short-lived. Approximately 30 minutes. MUST follow-up with PO carbohydrate dense foods if able to tolerate PO
D5W or D10W drips
Advantages: Less irritating to veins, lower risk of overshooting to hyperglycemia
Disadvantages: takes slightly longer to administer. Less useful in patients with profound hypoglycemia
Pediatrics
Rule of 50s
the concentration of dextrose multiplied by the dosage (cc/kg) equals 50
Age | Dextrose concentration | Dose |
<1yo | D10 | 5 cc/kg |
1-8yo | D25 | 2 cc/kg |
>8yo | D50 | 1 cc/kg |
Oral glucose
If patient is awake and able to tolerate PO, ALWAYS give PO. This is the most efficient way to provide carbohydrates with appropriately sustained glucose levels
1L IV D5W contains 50g glucose. Typical infusion rates are 100cc/hr. This means that a patient will only get 5g glucose per hour!
Glucagon
MOA: releases endogenous glycogen storages
Dosage: IM/IV/SubQ 1mg may repeat in 15 minutes as needed
Note: may not be helpful in patients with deficient glycogen storages (hepatic diseases, chronic alcohol use)
Octreotide
Used for sulfonylurea induced hypoglycemia
MOA: Somatostatin analogue, reduces insulin secretion
Dosage:
IV/SubQ: 50-100mcg
May repeat every 6hrs
May use IV continuous infusion 50-125mcg/hr
Steroids
useful for adrenal insufficiency & insulin overdoses who require large amounts of dextrose infusions
Dosage: hydrocortisone IV: 50mg q6hrs or 100mg q8hrs
Disposition
May discharge after 4-6hrs of observation if:
glucose remains stable
patient able to tolerate PO
Symptomatically resolved
Etiology identified with unlikely recurrence
Admission if the above criteria are not met
Jin Yao Li, DO
References
Balentine JR, Gaeta TJ, Kessler D, Bagiella E, Lee T. Effect of 50 milliliters of 50% dextrose in water administration on the blood sugar of euglycemic volunteers. Acad Emerg Med. 1998;5(7):691-694. doi:10.1111/j.1553-2712.1998.tb02487.x
Murthy MS, Duby JJ, Parker PL, Durbin-Johnson BP, Roach DM, Louie EL. Blood glucose response to rescue dextrose in hypoglycemic, critically ill patients receiving an insulin infusion. Ann Pharmacother. 2015;49(8):892-896. doi:10.1177/1060028015585574
Adler PM. Serum glucose changes after administration of 50% dextrose solution: pre- and in-hospital calculations. Am J Emerg Med. 1986;4(6):504-506. doi:10.1016/S0735-6757(86)80004-3
Farkas J. Hypoglycemia. EMCrit Project. Published April 1, 2023. https://emcrit.org/ibcc/hypoglycemia/
Donaldson R, Fadial T, Ostermayer D, et al. Hypoglycemia - WikEM. wikem.org. Published September 28, 2019. Accessed January 21, 2024. https://wikem.org/wiki/Hypoglycemia