| Clinical features |
- Any patient with acute change in mental status or coma should undergo rapid assessment of blood glucose as a possible cause.
- All findings of hypoglycemia are nonspecific, including the following:
- Autonomic response (tends to occur with blood glucose below 65 mg/dL)
- Sweating
- Weakness
- Tachycardia
- Palpitations
- Tremor
- Nervousness
- Hunger
- Paresthesias
- Neuroglycopenia
- Irritability
- Confusion
- Uncharacteristic behavior
- Seizure
- Occasionally, transient focal neurologic deficits
- Loss of consciousness
- Visual disturbance
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| Diagnostic evaluation |
- Obtain blood glucose concentration as soon as possible (usually with a meter and strips, if available):
- For symptomatic patient known to have diabetes and with a low glucose value (<70 mg/dL [3.89 mmol/L]), administer treatment. If a glucose test cannot be performed, do not delay. Treat as if hypoglycemia has been confirmed.
- If the glucose is low (<55 mg/dL) and the patient does not have diabetes, draw blood for glucose, insulin, C-peptide, and an oral hypoglycemic agent screen, and then treat.
- Do not delay treatment if symptomatic hypoglycemia is suspected but rapid blood glucose measurement is not available or blood for diagnostic studies cannot be collected.
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| Treatment |
- If the patient is conscious and able to drink and swallow safely (ie, alert enough to do so and with gag reflex intact), administer a rapidly absorbed carbohydrate (eg, 3 to 4 glucose tablets or a tube of gel with 15 grams, 4 to 6 oz fruit juice or non-diet soda, or a teaspoon of honey or table sugar).*
- If the patient has altered mental status, is unable to swallow, or does not respond to oral glucose administration within 15 minutes, give an IV bolus of 12.5 to 25 g of glucose (25 to 50 mL of 50% dextrose).
- Measure a blood glucose 10 to 15 minutes after the IV bolus. Re-administer 12.5 to 25 grams of glucose as needed to maintain the blood glucose above 80 mg/dL.
- If glucose cannot be given by parenteral or oral routes, give glucagon 1 mg IM or subcutaneously. Response may be transient and should be followed by careful glucose monitoring and oral or IV glucose administration.
- Give additional maintenance glucose by mouth or IV. IV dextrose infusion should ensure delivery of 6 to 9 mg/kg per minute of glucose. Amounts needed vary depending upon the cause and severity of the symptomatic hypoglycemia. Once the patient is able to ingest carbohydrate safely, providing a mixed meal (including carbohydrates, such as a sandwich) is the preferred means of maintaining glucose levels.
- Measure a blood glucose 10 to 15 minutes after the initial IV bolus and monitor every 30 to 60 minutes thereafter until stable (minimum of 4 hours). The measurement method should provide rapid turnaround, preferably at the point of care.
- Admit patients with ingestion of a long-acting hypoglycemic agent, recurrent hypoglycemia during observation, and those unable to eat.
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