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Hypoglycemia in diabetics is usually a complication of treatment with insulin or sulfonylureas (chlorpropamide, glyburide, glipizide). Hypoglycemia is unlikely due to the glitizones (rosiglitazone, pioglitazone), glinides (repaglinide, nateglinide), alpha-glucosidase inhibitors (acarbose, miglitol), and rare, if ever, due to the biguanide metformin, the incretin analogues (exenatide, liraglutide), or the amylin analogue pramlintide.

Clinical Features

Typical signs and symptoms of hypoglycemia include sweating, shakiness, anxiety, nausea, dizziness, palpitations, slurred speech, blurred vision, headache, seizure, focal neurologic deficits, and altered mental status ranging from confusion to coma.

Diagnosis and Differential

The diagnosis is based on detecting low blood glucose during the occurrence of typical signs and symptoms which resolve with treatment. Hypoglycemia can easily be misdiagnosed as a neurologic or psychiatric condition. The differential diagnosis includes stroke, seizure disorder, head injury, multiple sclerosis, psychosis, depression, and alcohol or drug intoxication.

Emergency Department Care and Disposition

  1. Administer glucose. Provide a carbohydrate meal when the patient can tolerate PO. Treat 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 mg/dL.

  2. Administer glucagon 1 mg IM or SC if there is no IV access.

  3. Treat refractory hypoglycemia secondary to the sulfonylureas with octreotide 50 to 100 μg SC. A continuous infusion of 125 μg/h may be required.

  4. Repeat blood glucose every 30 minutes initially to monitor for rebound hypoglycemia.

  5. Disposition depends on 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 carbohydrate intake and monitor their glucose. Patients with hypoglycemia due to the sulfonylureas or long acting insulins should be admitted due to the risk of rebound from these agents. See Table 129-1 for admission guidelines.

Table 129-1

Disposition/Guidelines for Hospital Admission


Diabetic ketoacidosis (DKA) results from a relative insulin deficiency and counter-regulatory hormone excess causing hyperglycemia and ketonemia. Table 129-2 lists important causes.

Table 129-2

Important Causes of Diabetic Ketoacidosis

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