1. Hypoglycemia - Symptoms Sweating Tachycardia Anxiety Hunger Paresthesias Palpitations Altered LOC Dizziness Seizures Coma Blurred vision Hypothermia Discharge of the sympathetic nervous system Central nervous system glucose deprivation

2. Whipples Triad Documented hypoglycemia Symptoms Symptoms resolve w/ Glucose

3. Hypoglycemia Fasting (Post absorptive) –If reproducible, implies disease, requires w/u –Occurs after a fast or exercise –Do an overnight fast –Etiology Drugs Critical illness Hormonal deficiencies Hyperinslinism Reactive ( Post prandial) –Reactive –Usually not serious, self limiting –Etiology Idiopathic, s/p gastric surgery, rarely enzyme defect

4. Etiology –Fasting hypoglycemia Alimentary hyperinsulinism Hereditry fructose intolerance Galactosemia Leucine Sensitivity Idiopathic Artifact –Leukocytosis –Polycythemia

5. Etiology –Fasting hypoglycemia Endocrinopathy –Adrenal insufficiency –Hypopituitary –Glucogon deficiency –Catacholamine deficiency Starvation Organic –Acute liver failure –Chronic renal failure –Acute CHF Drugs –Alcohol Propanolol, Salicilates Hypothermia Overutilization of Glucose Drugs –Insulin,, Sulfonylureas, Quinine, Disopyramine, Pentamidine, Sulfonamides Tumor –Insulinoma Infection –Septicemia, Malaria Impaired production

6. Hypoglycemia Emergency Department Presentation –2/3 Hx Diabetes –2/3 Recent ETOH use –1/4 Septic –Comment: Think of hypoglycemia in septic, drunk diabetics Hospitalized –60% Drugs (Insulin, sulfonylureas, ETOH) –15% Renal disease –15% Liver disease –Others malnutrition and sepsis

7. Work Up Identification Hx & PE Collect blood during hypoglycemic episode –Check Glucose, –Draw and hold blood for Insulin (C-peptide and Proinsulin) and specific drug screen Treatment –Glucose Repeat serum glucose –Treat primary problem

8. Admission/Discharge Resolved hypoglycemia Resolution of symptoms Identification of primary problem –Severity –Likelihood or reoccurrence –Use caution w/ patients on long acting oral hypoglycemics Food Social issues –Food –Live alone –Was this an OD? Are there hypoglycemic drugs in the home? Healthcare worker

9. Clinical Pearls In diabetics, hypoglycemia is almost always related to medication In a nondiabetic with confusion, LOC, Sz, a workup is required Hypoglycemia in a nondiabetic w/o sepsis. Liver dz, renal dz, or Hx of ETOH should raise the suspicion of an insulinoma, tumor, hormonal, etc

10. More Pearls Poorly controlled IDDM will suffer hypoglycemia at a higher glucose level Pt w/ controlled IDDM and insulinomas can tolerate lower glucose levels Neurohypoglycemia ~ 54 Arterial gluc levels are higher (30%) Use caution in pts on beta blockers