Hypoglycemia

Hypoglycemia:  deficiency of glucose concentration in the blood, which may lead to nervousness, hypothermia, headache, confusion, and sometimes convulsions and coma.  Hypoglycemia is characterized by an abnormally low glucose level, hypoglycemia occurs when glucose is used too rapidly, when the glucose release rate falls behind tissue demands, or when excessive insulin enters the blood stream.  This deficiency is classified as reactive or fasting. Reactive hypoglycemia results from the reaction to the disposition of meals or the administration of excessive amount of insulin.  Fasting hypoglycemia causes discomfort during long periods of not eating food, for example: in the early morning hours before breakfast.  Hypoglycemia is a specific endocrine imbalance, its symptoms are often vague and depend on how quickly the patient's glucose levels drop.  If not treated properly, severe hypoglycemia may result in coma and irreversible brain damage.

Cause:  Reactive hypoglycemia can result from too much insulin or oral hypoglycemic medication in diabetic patients.  It can also result form impaired glucose tolerance, with early hyperglycemia followed by a delayed rise in insulin levels: rapid small intestine glucose absorption caused by gastrectomy or other GI procedures; and it can be idiopathic.
Fasting hypoglycemia can be  caused by exogenous factors, such as alcohol or drug ingestion, or endogenous factors caused by organ damage, such as pancreatic tumor, hepatic disease, or renal disease.

Symptoms:

Weakness
Hunger
Cold sweats
Shakiness
Trembling
Headache
Irritability
Tachycardia
Pallor
Blurred vision
Confusion
Motor weakness
Hemiplegia
Convulsions
Coma

Treatment:

For acute hypoglycemia:  First priority is to bring the patient's glucose level back to normal.
Effective long term treatment of reactive hypoglycemia requires dietary modification.
If conscious, the patient needs a fast acting carbohydrate, such as sweetened orange juice or candy (than follow with doctors orders)
If unconscious:  Medical emergency - Go see a doctor or ER promptly.  The doctor may prescribed glucagon I.M. or S.C. or an I.V. bolus of 50 ml of dextrose 50% is usually administered first.

For fasting hypoglycemia:  surgery and drug therapy are usually required.


Comparing Hypoglycemia, Diabetic Ketoacidosis (DKA), and Hyperglycemic Hyperosmolar Nonketotic Coma (HHNC)

Hypoglycemia:

Precipitating factors:  Delayed or omitted meal, insulin overdose, excessive exercise without food or insulin adjustments.

Symptom onset:  Rapid - can be minutes to hours

Signs and symptoms:  Skin and Mucous membranes:  Cold, clammy skin, pallor, profuse sweating, normal mucous membranes.
Neurologic status:   Initial state -Irritability, nervousness, hand tremors, may have difficulty speaking, and concentrating, difficulty focusing, and coordinating. - Late state- - Dilated pupils, hyper-reflexia, Coma.
Muscle strength:  Normal or reduced
GI:  None
Temperature:  Normal, if in deep coma- may be subnormal
Pulse:  Tachycardic (abnormally rapid pulse rate), if in deep coma - bradycardic (abnormally low pulse rate)
Blood pressure:  Normal to above normal
Respirations:  Initial state:  normal to rapid. - Late state: slow
Breath odor:  Normal
Other:  Hunger

Treatment:  Glucose, glucagon, epinephrine


Diabetic Ketoacidosis (DKA)

Precipitating factors:  Undiagnosed diabetes, Neglected treatment, infection, cardiovascular disorders, physical stress, emotional stress, and Exercise in uncontrolled diabetes

Symptom onset:  Slow - can be hours to days

Signs and symptoms:  Skin and Mucous membranes:  Warm, flushed, dry, loose skin; dry, crusty mucous membranes; soft eyeballs
Neurologic status:  Initial state:  dullness, confusion, lethargy; diminished reflexes. -Late state: coma
Muscle strength:  Extremely weak
GI:  Anorexia, nausea, vomiting, diarrhea, abdominal tenderness and pain
Temperature:  Hypothermia, Patient may have a fever - from dehydration or infection.
Pulse:  Mildly tachycardic, weak
Blood pressure:  Subnormal
Respirations:  Initial state:  deep, fast. - Late state:  Kussmaul's (deep rapid respiration)
Breath odor:  Fruity, acetone
Other:  Thirst

Treatment:  Insulin, fluid replacement, electrolyte replacement, anti acidosis therapy (if needed)



Hyperglycemic Hyperosmolar Nonketotic Coma (HHNC)

 
Precipitating factors:  Undiagnosed diabetes, infection or other stress, acute or chronic illnesses, certain drugs and medical procedures, severe burns treated with high glucose concentrations

Symptom onset:  Slow - can be hours to days, but more gradual than DKA

Signs and symptoms:  Skin and Mucous membranes:  Warm, flushed, dry, extremely loose skin; dry, crusty mucous membranes; soft eyeballs
Neurologic status:  Initial state:  dullness, confusion, lethargy, diminished reflexes. - Late state:  Coma
Muscle strength:  Extremely weak
GI:   None
Temperature:  May have a fever (usually from dehydration or infection)
Pulse:  Usually rapid
Blood pressure:  Subnormal
Respirations:  Rapid (not like DKA)
Breath odor:  Normal
Other:  Initial - Thirst  - Late- Thirst may be absent

Treatment:  Fluid replacement, insulin, electrolyte replacement

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