Hypoglycaemia

Question 1

What are causes of hypoglycaemia in a diabetic patient?

Answer 1

Insulin or sulphonylurea use plus other factors:

• Exercise
• Missed meal
• Overdose

Question 2

What are causes of hypoglycaemia in non-diabetic patients?

Answer 2

• Exogenous drugs
• Pituitary insufficiency
• Liver failure
• Addison’s disease
• Islet cell tumours
• Non-pancreatic neoplasms

Question 3

What are examples of exogenous drugs which can cause hypoglycaemia?

Answer 3

• Insulin
• Alcohol use
• Aspirin poisoning
• ACE-i
• B-blockers
• IGF-1
• Pentamidine

Question 4

What are the main symptom/sign groupings of hypoglycaemia?

Answer 4

• Autonomic syptoms/signs
• Neuroglycopenic symptoms/signs

Question 5

What are the autonomic features of hypoglycaemia?

Answer 5

• Sweating
• Anxiety
• Hunger
• Tremor
• Palpitations
• Dizziness

Question 6

What a neuroglycopenic features of hypoglycaemia?

Answer 6

• Confusion/Irritability
• Drowsiness
• Visual trouble
• Seizures
• Coma
• Focal features - rare

Question 9

What is the definition of hypoglycaemia?

Answer 9

BG of <3 mmol/L

Question 10

What investigation would you do in someone with suspected hypoglycaemia?

Answer 10

Blood glucose - most important test

• Cap glucose
• Lab glucose

Consider tests for suspected cause

• LFTs
• Addison’s test
• Insulin levels
• C-peptide
• Proinsulin

Question 11

When interpreting results, what could cause hypoglycaemic hyperinsulinaemia?

Answer 11

• Insulinoma
• Sulphonylurea
• Insulin injection
• Mutation of insulin receptor gene

Question 12

How could you tell if someone with hypoglycaemia had taken injectable insulin overdose based on blood results?

Answer 12

No c-peptide present in the blood, but hyperinsulinaemia

Question 13

How would you manage mild hypoglycaemia?

Answer 13

15-20g quick acting carbohydrates

5-7 dextrose tablets/4-5 glucotabs

OR

170-220 mls original lucozade

OR

150-200 mls pure fruit juice

Question 14

If someone had low insulin and high ketones and had hypoglycaemia, what could be the cause?

Answer 14

• Alcohol
• Pituitary insufficiency
• Addison’s Disease

Question 15

When would you consider giving further treatment for mild hypoglycaemia?

Answer 15

If BG is <4 mmol/L after 15 minutes of giving 15-20g quick acting carbohydrates, repeat initial management up to 3 times

Question 16

If after treating someone repeatedly for mild hypoglycaemia with oral carbohydrate solutions, what would you consider?

Answer 16

IV 10% glucose - 100 ml/hr

OR

1 mg Glucagon IM

Question 17

How would you manage moderate hypoglycaemia?

Answer 17

If capable/cooperative - same as mild hypoglycaemia treatment

If not capable/cooperative

• 1.5-2 tubes glucogel

If ineffective - 1mg Glucagon IM

Question 18

If, after giving repeated treatments with glucogel (or 1 mg glucagon) for moderate hypoglycaemia, what would you consider giving?

Answer 18

IV 10% glucose at 100 ml/hr

Question 19

What is classed as mild hypoglycaemia?

Answer 19

• Patient conscious
• Able to swallow
• Orientated

Question 20

How would you manage someone with severe hypoglycaemia?

Answer 20

• Check ABC
• Stop IV insulin
• Give 75 ml IV 20% glucose OR 1mg Glucagon IM

Question 21

How soon after giving treatment for severe hypoglycaemia would you recheck someones blood glucose?

Answer 21

10 minutes

Question 22

What would you give someone who’s blood sugar (after treating them initially) was above 4 mmol/L?

Answer 22

20g long acting carbs

• Two biscuits
• Slice of bread
• 200-300 ml milk

If IM glucagon used - use 40 g long acting carbs

Question 23

If someone was nil by mouth after getting their blood glucose above 4 mmol/L, how would you manage them?

Answer 23

IV 10% glucose - 100 ml/hr

Question 25

What is classed as moderate hypoglycaemia?

Answer 25

• Patient conscious
• Able to swallow
• Confused/Disorientated/Aggressive

Question 30

What is classed as severe hypoglycaemia?

Answer 30

• Unconscious/Fitting
• Aggressive
• Nil by mouth

Question 35

When should a patient advise the DVLA of their condition?

Answer 35

If treated by diet only - dont need to tell DVLA

Need to tell DVLA if:

• More than one episode of severe hypoglycaemia within the last 12 months.
• High risk of developing severe hypoglycaemia.
• Loss of hypoglycaemic awareness
• Suffer severe hypoglycaemia while driving.
• Need treatment with insulin.
• Need laser treatment to both eyes or in the remaining eye if you have sight in one eye only.
• Problems with vision in both eyes, or in the remaining eye if you have sight in one eye only.

Question 36

What dose of glucagon is used to treat hypoglycaemia?

Answer 36

1mg

Question 37

How is glucagon administered?

Answer 37

IM

Question 38

What rate would you give someone IV 10% glucose to treat unresponsive mild/moderate hypoglycaemia?

Answer 38

100 mls/hr

Question 39

What volume of IV 20% glucose would you give someone with severe hypoglycaemia (unconscious patient)?

Answer 39

75ml 20% glucose

Question 40

What concentrations of IV glucose might you give someone with severe hypoglycaemia (are unconscious)?

Answer 40

10% glucose or 20% glucose (different volumes) depending on concentration

Question 41

What volume of IV 10% glucose would you give someone with severe hypoglycaemia (unconscious patient)?

Answer 41

150ml 10% glucose

Question 42

What rate should IV glucose be given at in severe/unresponsive hypoglycaemia?

Answer 42

IV STAT

Question 43

When may glucagon be ineffective?

Answer 43

* **In severe liver disease** * **Undernourished patients**

Question 44

How might having given glucagon influence subsequent management with long acting carbohydrates once blood glucose levels begin to rise?

Answer 44

40g long acting carbs, not 20g