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 Associated conditions insulinoma chronic alcohol use beta blockers Addison disease factitious disorder fructose intolerance liver failure kidney failure Epidemiology Risk factors diabetes side effect of medications insulin sulfonylurea more common in type I older age alcohol ingestion 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