Nondiabetic hypoglycaemic coma

Emergency Medicine

Clinicals - History

Fact Explanation
Tiredness Lethargy and tiredness are neuroglycopenic symptoms that occur due to a reduction, in cerebral glucose. Tiredness
Lethargy and tiredness are neuroglycopenic symptoms that occur due to a reduction, in cerebral glucose.
Inappropriate behavior A neuroglycopenic symptom, however sympatho-adrenal activation can cause anxiety that may also manifest as a change in behavior. Inappropriate behavior
A neuroglycopenic symptom, however sympatho-adrenal activation can cause anxiety that may also manifest as a change in behavior.
Blurred vision Diplopia and blurred vision occurs as a neuroglycopenic symptom in hypoglycemia. Blurred vision
Diplopia and blurred vision occurs as a neuroglycopenic symptom in hypoglycemia.
Seizures Insulinomas may present as a recurrent seizure disorder. A neuroglycopenic symptom that occurs due to a lack of glucose needed in the function of cerebral neurons. Delay in diagnosis/misdiagnosis of hypoglycemic seizures can lead to permanent neurological damage or coma. Seizures
Insulinomas may present as a recurrent seizure disorder. A neuroglycopenic symptom that occurs due to a lack of glucose needed in the function of cerebral neurons. Delay in diagnosis/misdiagnosis of hypoglycemic seizures can lead to permanent neurological damage or coma.
Palpitations Palpitations occur due to the activation of the sympatho-adrenal system, in response to the hypoglycemia. Other sympatho-adrenal symptoms include: tremors and diaphoresis. Usually sympatho-adrenal symptoms precede neuroglycopenic sypmtoms. However in tumor induced hypoglycemia (TIH) commonly due to an insulinoma, neuroglycopenia may occur first. Palpitations
Palpitations occur due to the activation of the sympatho-adrenal system, in response to the hypoglycemia. Other sympatho-adrenal symptoms include: tremors and diaphoresis. Usually sympatho-adrenal symptoms precede neuroglycopenic sypmtoms. However in tumor induced hypoglycemia (TIH) commonly due to an insulinoma, neuroglycopenia may occur first.
Coma Prolonged periods of hypoglycemia can cause a coma, which occurs due to a reduction in cerebral glucose that is essential for the function of neurons. Coma
Prolonged periods of hypoglycemia can cause a coma, which occurs due to a reduction in cerebral glucose that is essential for the function of neurons.
Death Prolonged periods of hypoglycemia leads to non reversible brain damage, and results in death. Death
Prolonged periods of hypoglycemia leads to non reversible brain damage, and results in death.
History of heavy ethanol ingestion Heavy ethanol ingestion induces hypoglycemia by inhibiting gluconeogenesis. History of heavy ethanol ingestion
Heavy ethanol ingestion induces hypoglycemia by inhibiting gluconeogenesis.
History of starvation Patients who have undertaken hunger strikes or been deprived of food for long periods (elderly, the critically ill, fasting for religious festivals and hostage victims) are at risk of hypoglycemia due to reduced intake of glucose. History of starvation
Patients who have undertaken hunger strikes or been deprived of food for long periods (elderly, the critically ill, fasting for religious festivals and hostage victims) are at risk of hypoglycemia due to reduced intake of glucose.
History of attempted suicide/ poisining A psychiatric history should be elicited. A history of depression or previous attempts of deliberate self harm (DSH) should raise the possibility of attempted suicide. This possibility should especially be entertained in health workers and those with access to insulin (relatives, caregivers of diabetics) . Other drugs used are: sulfonylureas and meglitinides History of attempted suicide/ poisining
A psychiatric history should be elicited. A history of depression or previous attempts of deliberate self harm (DSH) should raise the possibility of attempted suicide. This possibility should especially be entertained in health workers and those with access to insulin (relatives, caregivers of diabetics) . Other drugs used are: sulfonylureas and meglitinides
History of inherited metabolic disease Inborn errors of metabolism, most of which have a recessive inheritance, are an important cause of hypoglycemia in the non diabetic. They can be classified in to three groups: intoxication diseases (i.e., amino-acidopathies, organic aciduria, fructose intolerance and galactosaemia, iron and copper overload, porphyria); diseases linked to energy deficiency (i.e., glycogenolysis, mitochondrial diseases, disorders of fatty acid oxidation and ketogenesis, congenital lactic acidosis); and diseases due to degradation or synthesis defect of complex molecules (i.e.lysosomal or peroxisomal diseases, and congenital disorders of glycosylation.) History of inherited metabolic disease
Inborn errors of metabolism, most of which have a recessive inheritance, are an important cause of hypoglycemia in the non diabetic. They can be classified in to three groups: intoxication diseases (i.e., amino-acidopathies, organic aciduria, fructose intolerance and galactosaemia, iron and copper overload, porphyria); diseases linked to energy deficiency (i.e., glycogenolysis, mitochondrial diseases, disorders of fatty acid oxidation and ketogenesis, congenital lactic acidosis); and diseases due to degradation or synthesis defect of complex molecules (i.e.lysosomal or peroxisomal diseases, and congenital disorders of glycosylation.)

Clinicals - Examination

Fact Explanation
Confusion A neuroglycopenic symptom, that occurs due to a reduction in glucose concentration, which is vital for the function of cerebral neurons. Confusion
A neuroglycopenic symptom, that occurs due to a reduction in glucose concentration, which is vital for the function of cerebral neurons.
Diaphoresis Occurs due to the activation of the sympatho-adrenal system in response to hypoglycemia. Diaphoresis
Occurs due to the activation of the sympatho-adrenal system in response to hypoglycemia.
Tremors A sympatho-adrenal symptom of hypoglycemia. Tremors
A sympatho-adrenal symptom of hypoglycemia.
Arterial hypertension Adrenergic overactivity, due to activation of the sympatho-adrenal system. Arterial hypertension
Adrenergic overactivity, due to activation of the sympatho-adrenal system.
Irregular pulse Severe hyperinsulinemic hypoglycemia can cause cardiac arrhythmia due to hypokalemia, as insulin causes potassium influx into the cells. Irregular pulse
Severe hyperinsulinemic hypoglycemia can cause cardiac arrhythmia due to hypokalemia, as insulin causes potassium influx into the cells.

Investigations - Diagnosis

Fact Explanation
Capillary Blood Sugar (CBS) Diagnosis of pathological hypoglycemia is confirmed by the Whipple triad: symptoms of hypoglycemia, a low plasma glucose level and resolution of symptoms and signs once normoglycemia is achieved. Though CBS is not always accurate, it provides rapid results (as delaying treatment can disastrous consequences) and a low CBS should be followed by subsequent laboratory investigation of plasma glucose. A glucose level of less than 55mg/dl (3 mmol/L) supported by the Whipple triad establishes the diagnosis of hypoglycemia in a non diabetic. Capillary Blood Sugar (CBS)
Diagnosis of pathological hypoglycemia is confirmed by the Whipple triad: symptoms of hypoglycemia, a low plasma glucose level and resolution of symptoms and signs once normoglycemia is achieved. Though CBS is not always accurate, it provides rapid results (as delaying treatment can disastrous consequences) and a low CBS should be followed by subsequent laboratory investigation of plasma glucose. A glucose level of less than 55mg/dl (3 mmol/L) supported by the Whipple triad establishes the diagnosis of hypoglycemia in a non diabetic.

Investigations - Management

Fact Explanation
Full Blood Count Important baseline investigation, symptoms of severe anemia may mimic hypoglycemia and cause lethargy, weakness. In addition a leucocytocis is suggestive of an infection that will also cause hypoglycemia. Full Blood Count
Important baseline investigation, symptoms of severe anemia may mimic hypoglycemia and cause lethargy, weakness. In addition a leucocytocis is suggestive of an infection that will also cause hypoglycemia.
C Reactive Protein To asses the presence of an infective process, that may have precipitated the hypoglycemia. C Reactive Protein
To asses the presence of an infective process, that may have precipitated the hypoglycemia.
Serum Insulin In exogenous hypoglycemia, the level of insulin is elevated (more than 3 micoIU/ml). Serum Insulin
In exogenous hypoglycemia, the level of insulin is elevated (more than 3 micoIU/ml).
C Peptide In hypoglycemia due to exogenous insulin despite an elevated insulin level, C-peptide is low (less than 0.6 ng/mL). This helps exclude DSH using sulfonylureas as this causes increased secretion of endogenous insulin, thus there is an increase in both insulin and C-peptide. C Peptide
In hypoglycemia due to exogenous insulin despite an elevated insulin level, C-peptide is low (less than 0.6 ng/mL). This helps exclude DSH using sulfonylureas as this causes increased secretion of endogenous insulin, thus there is an increase in both insulin and C-peptide.
Serum Cortisol The possibility of primary adrenal insufficiency should be entertained. As it can cause symptoms of hypoglycemia due to cortisol deficiency. Serum Cortisol
The possibility of primary adrenal insufficiency should be entertained. As it can cause symptoms of hypoglycemia due to cortisol deficiency.
TSH/fT4/fT3 Should be performed in the investigation of non diabetic hypoglycemia for several reasons. Firstly hypothyroidism may mimic symptoms of hypoglycemia. Secondly, pituitary insufficiency can lead to hypoglycemia, due to inactivation of the hypothalamo-pituitary-adrenal axis, thyroid hormone secretion will be depressed in this situation. Rarely a thyrotoxic crisis can precipitate hypoglycemia, (though it commonly causes impaired glucose tolerance). TSH/fT4/fT3
Should be performed in the investigation of non diabetic hypoglycemia for several reasons. Firstly hypothyroidism may mimic symptoms of hypoglycemia. Secondly, pituitary insufficiency can lead to hypoglycemia, due to inactivation of the hypothalamo-pituitary-adrenal axis, thyroid hormone secretion will be depressed in this situation. Rarely a thyrotoxic crisis can precipitate hypoglycemia, (though it commonly causes impaired glucose tolerance).
Liver Enzymes/Liver Function Tests Liver failure is a cause for hypoglycemia, as it depresses hepatic gluconeogenesis during periods of fasting. Therefore assessment of the liver enzymes and liver function tests is needed. Liver Enzymes/Liver Function Tests
Liver failure is a cause for hypoglycemia, as it depresses hepatic gluconeogenesis during periods of fasting. Therefore assessment of the liver enzymes and liver function tests is needed.
CT Abdomen For the diagnosis of an insulinoma, they are hypervascular and, as a result, demonstrate a greater degree of enhancement than normal pancreatic parenchyma during the arterial and capillary phases of contrast. CT Abdomen
For the diagnosis of an insulinoma, they are hypervascular and, as a result, demonstrate a greater degree of enhancement than normal pancreatic parenchyma during the arterial and capillary phases of contrast.
MRI Abdomen The sensitivity and specificity of MRI is higher than CT for the diagnosis of an insulinoma, despite its advantages it is the second line investigation in current practice. MRI Abdomen
The sensitivity and specificity of MRI is higher than CT for the diagnosis of an insulinoma, despite its advantages it is the second line investigation in current practice.

Management - Supportive

Fact Explanation
Secure Airway, Breathing and Circulation Initial management and resuscitation of any unconscious patient should involve management of airway, breathing and circulation. Decision to intubate should be made with assessment of the Glasgow Coma Scale (GCS); if less than 8 elective intubation should be performed as the patient's airway protection reflexes are absent. Supplemental oxygen and IV fluids can be administered, in pre-hospital care or when encountered at the emergency department. Secure Airway, Breathing and Circulation
Initial management and resuscitation of any unconscious patient should involve management of airway, breathing and circulation. Decision to intubate should be made with assessment of the Glasgow Coma Scale (GCS); if less than 8 elective intubation should be performed as the patient's airway protection reflexes are absent. Supplemental oxygen and IV fluids can be administered, in pre-hospital care or when encountered at the emergency department.
Continous monitoring Continuous monitoring of the patient should occur during the initial assessment and resuscitation. This should include monitoring of pulse, blood pressure, oxygen saturation and capillary blood sugar (CBS). Continous monitoring
Continuous monitoring of the patient should occur during the initial assessment and resuscitation. This should include monitoring of pulse, blood pressure, oxygen saturation and capillary blood sugar (CBS).

Management - Specific

Fact Explanation
Pre-hospital care If possible an oral carbohydrate dose should be administered, prior to hospital admission. Initial load can be provided with oral glucose, a 15-20g dose will maintain euglycemia for approximately 2 hours. Therefore it should be followed by a complex carbohydrate meal, to maintain euglycemia for a longer period. Pre-hospital care
If possible an oral carbohydrate dose should be administered, prior to hospital admission. Initial load can be provided with oral glucose, a 15-20g dose will maintain euglycemia for approximately 2 hours. Therefore it should be followed by a complex carbohydrate meal, to maintain euglycemia for a longer period.
Admission criteria Admission to a hospital is mandatory in a non diabetic patient with hypoglycemia, where a secondary cause is suspected. This is for further investigation in to the etiology. Non response to treatment at primary care is another indication. Admission criteria
Admission to a hospital is mandatory in a non diabetic patient with hypoglycemia, where a secondary cause is suspected. This is for further investigation in to the etiology. Non response to treatment at primary care is another indication.
Intravenous Thiamine In a patient presenting with chronic malnutrition or alcohol abuse, IV Thiamine should be administered prior to dextrose therapy to prevent Wernicke's encephalopathy. Bolus of 1-2 mg/kg. Intravenous Thiamine
In a patient presenting with chronic malnutrition or alcohol abuse, IV Thiamine should be administered prior to dextrose therapy to prevent Wernicke's encephalopathy. Bolus of 1-2 mg/kg.
Dextrose Management of hypoglycemia is with dextrose. When the plasma insulin level reach 50-60microIU/ml, hepatic gluconeogensis becomes completely suppressed. Thus dextrose is necessary. The objective of an acute intervention is to minimize cerebral damage, therefore dextrose infusion should commence once it is suggested by a low CBS (save plasma for a late laboratory investigation of venous glucose). Initial administration of 25-50 ml of 50% Dextrose, should be followed by a saline flush. Subsequent 10% dextrose should be titrated according to clinical response, plasma venous glucose levels and food intake. Dextrose
Management of hypoglycemia is with dextrose. When the plasma insulin level reach 50-60microIU/ml, hepatic gluconeogensis becomes completely suppressed. Thus dextrose is necessary. The objective of an acute intervention is to minimize cerebral damage, therefore dextrose infusion should commence once it is suggested by a low CBS (save plasma for a late laboratory investigation of venous glucose). Initial administration of 25-50 ml of 50% Dextrose, should be followed by a saline flush. Subsequent 10% dextrose should be titrated according to clinical response, plasma venous glucose levels and food intake.
Glucagon Glucagon stimulates hepatic gluconeogenesis, and an emergency dose of IM/SC Glucagon 1 mg can be administered. This unhelpful where hepatic function is depressed, i.e. liver failure, ethanol induced hypoglycemia and adrenal insufficiency. Glucagon
Glucagon stimulates hepatic gluconeogenesis, and an emergency dose of IM/SC Glucagon 1 mg can be administered. This unhelpful where hepatic function is depressed, i.e. liver failure, ethanol induced hypoglycemia and adrenal insufficiency.
Subsequent measures following stabilization Following stabilization, management should be aimed at maintaining euglycemia and on investigating the cause of hypoglycemia. Subsequent measures following stabilization
Following stabilization, management should be aimed at maintaining euglycemia and on investigating the cause of hypoglycemia.

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