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Snapshot
  • A 25-year-old male is brought to the emergency department by ambulance for loss of consciousness. He is accompanied by his girlfriend. His girlfriend states that she and the patient had gone out for his birthday. He had taken more insulin than usual because he knew he was going to eat and drink. A couple of hours later, he appeared “groggy” and then fainted. The patient has insulin dependent diabetes mellitus. He takes glargine and lispro. On physical examination, he is somnolent.
Introduction
  • Clinical definition
    • low blood glucose
      • often defined as < 70 mg/dL
  • Epidemiology
    • risk factors
      • diabetes
        • side effect of medications
          • insulin
          • sulfonylurea
        • more common in type I
      • older age
      • alcohol ingestion
  • Associated conditions
    • insulinoma
    • chronic alcohol use
    • beta blockers
    • Addison disease
    • factitious disorder
    • fructose intolerance
    • liver failure
    • kidney failure
Presentation
  • Symptoms 
    • palpitations
    • sweating
    • anxiety
    • nausea/vomiting
    • dizziness
    • confusion
    • seizure
  • Physical exam
    • tremor
    • tachycardia
    • altered mental status
    • somnolence/coma
Evaluation
  • Diagnostic testing
    • diagnostic approach
      • fingerstick blood glucose should be checked for any patient presenting with altered mental status
    • studies
      • blood glucose
        • best initial test
      • sulfonylurea level
      • exogenous insulin level
      • C-peptide level
        • will be low in patients using surreptitious insulin
        • will be elevated in insulinoma
Treatment
  • Management approach
    • differs if the patient is conscious or unconscious
  • First-line
    • if conscious
      • oral glucose or fast-acting carbohydrate
    • if unconscious
      • 50% intravenous (IV) dextrose
  • Second-line
    • intramuscular (IM) glucagon
      • indicated if no IV access
      • stimulates glucose production through glycogenolysis and gluconeogenesis
Complications
  • Falls
  • Death

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