Autonomic symptoms first, then neuroglycopenic
Expansion
Symptoms in two groups, appearing in order
- Autonomic, from about 3.6 mmol/l: sweating, tremor, palpitations, hunger, anxiety
- Neuroglycopenic, from about 2.8: confusion, drowsiness, slurred speech, odd behaviour, seizures, coma. Often mistaken for alcohol intoxication or stroke
Whipple’s triad confirms a genuine hypoglycaemic disorder: symptoms, a low measured glucose, and relief of symptoms on correcting it.
Treatment by conscious level
- Conscious and able to swallow: 15 to 20 g of quick acting carbohydrate, repeated after 15 minutes if needed, then a long acting carbohydrate
- Conscious but uncooperative: buccal glucose gel
- Unconscious or seizing: intravenous glucose (10 per cent, 150 to 200 ml) or intramuscular glucagon 1 mg
Glucagon fails where there is no glycogen: in liver disease, starvation, alcohol dependence and repeated hypoglycaemia, so it is unreliable in exactly the patients who often need it.
Always give the long acting carbohydrate afterwards, or the patient will relapse, particularly with sulphonylureas and long acting insulin, which may need admission and a glucose infusion.
Causes in a non-diabetic: alcohol, liver failure, Addison’s, sepsis, insulinoma (raised C-peptide), and factitious insulin (suppressed C-peptide).