1)  ABCs

2)  History

3)  Physical Examination

4)  Investigations

5)  Management


Initial management

•  for severe hypoglycemia, need to act quickly before pt has seizure or becomes comatose (usually occurs with BG<2.0 mmol/L)

•  if alert, have pt drink a cup of sweetened fruit juice

•  if obtunded, push 1 amp of D50W IV (has immediate onset of action)

•  if no IV access, give glucagon 1 mg IM/SC (onset of action 30 minutes)

•  do Accucheck q15min until BG>4.0 mmol/L


 Things to obtain on hx:

•  insulin regimen

•  last dose of insulin (when and how much was taken)

•  frequency of BG monitoring

•  prior episodes of hypoglycemia

•  most recent A1C

•  do they take full dose of insulin when they their po intake?

•  exercise regimen

•  carbohydrate intake

•  EtOH use (remember metabolism of EtOH reduces NAD to NADH, leading to gluconeogenesis)

•  hepatic or renal disease

•  autonomic neuropathy (may cause hypoglycemia unawareness)

•  history of  hypoglycemia unawareness

•  symptoms of adrenal insufficiency (particularly if pt is not on insulin or a sulfonylurea)

•  symptoms of an eating disorder

•  major ψ issues that may lead to insulin overdose

•  symptoms of infection



 •  A1C

 •  if surreptitious insulin/sulfonylurea use or insulinoma are on differential (i.e. if pt does not have hx of DM), then always obtain serum insulin, proinsulin, C-peptide and sulfonylurea levels during hypoglycemic episode



•  counsel pt regarding symptoms and management of hypoglycemia

•  ensure pt has MedicAlert bracelet

•  inform Ministry of Transportation

•  reassess insulin regimen/diabetes management

•  arrange diabetes f/u (family physician or endocrinologist)


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