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Hypoglycemia is usually a complication of treatment of diabetics with insulin or sulfonylureas (chlorpropamide, glyburide, glipizide). Hypoglycemia is an unusual reaction from treatment with the glitizones (rosiglitazone, pioglitazone), glinides (repaglinide, nateglinide), alpha-glucosidase inhibitors (acarbose, miglitol), or the biguanide metformin. Patients with diabetes, alcoholism, sepsis, adrenal insufficiency, hypothyroidism, or malnutrition are at risk for severe hypoglycemia.

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Clinical Features

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Typical symptoms of hypoglycemia include sweating, shakiness, anxiety, nausea, dizziness, confusion, slurred speech, blurred vision, headache, lethargy, and coma. Focal neurologic findings may include cranial nerve palsies, hemiplegia, seizures, and decerebrate posturing.

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Diagnosis and Differential

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A blood glucose level alone does not define hypoglycemia. The diagnosis is based on the glucose level in conjunction with typical symptoms that resolve with treatment. Hypoglycemia can easily be misdiagnosed as a primary neurologic or psychiatric condition (Table 129-1).

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Table Graphic Jump Location
Table 129-1 Differential Diagnosis of Hypoglycemia
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Emergency Department Care and Disposition

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  1. Treat hypoglycemic patients with altered mental status with 50% dextrose 50 mL IV. A continuous infusion of 10% dextrose solution may be required to maintain the blood glucose above 100 milligrams/dL. Provide a carbohydrate meal if the patient can tolerate po.

  2. If there is no IV access, administer glucagon 1 milligram IM or SC.

  3. Refractory hypoglycemia secondary to the sulfonylureas may respond to octreotide 50 to 100 micrograms SC. A continuous infusion of 125 micrograms/h may be required.

  4. Monitor for rebound hypoglycemia by determining blood glucose every 30 min initially.

  5. Disposition is determined by the patient's response to treatment, cause of hypoglycemia, comorbid conditions, and social situation. Most insulin reactions respond rapidly. Patients can be discharged with instructions to continue oral intake of carbohydrates and closely monitor their finger stick glucose. Patients with hypoglycemia due to the sulfonylureas or long acting insulins should be admitted due to the risk of recurrence from these agents. See Table 129-2 for admission guidelines.

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Table Graphic Jump Location
Table 129-2 Disposition/Guidelines for Hospital Admission
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Diabetic ketoacidosis (DKA) results ...

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