 Hello, and welcome to the emergency medicine video. This segment will be about hypoglycemia. You're working in the emergency department. This patient was brought in by his coworkers because of a decreased level of consciousness. They just couldn't wake him up. One of your nurses did a rapid bedside glucose. It is 1.2 millimoles per liter. Or in American units, 20mg per deciliter. What should we do? In this segment, we'll go through the definition of hypoglycemia, how the patients might present, and once they get to their emergency department, what should we do with them? First, how do we define hypoglycemia? It is defined as a serum blood glucose of less than 3.5 millimoles per liter, or 16mg per deciliter. Patients who have hypoglycemia should also have some symptoms of hypoglycemia. And once their hypoglycemia is being reversed, their symptoms also get better. Therefore we need to know the symptoms of hypoglycemia. They are divided into two main categories. They include neurological symptoms and symptoms due to high epinephrine in the body. In terms of neurological symptoms, they can include decreased level of consciousness, leading to lethargy, acoma. They can also have change in level of consciousness such as confusion and agitation. They can cause seizure. And sometimes it's so tricky that it causes focal neurological findings that mimic a stroke. With the fall in blood sugar, the body releases catecholamines. Epinephrine is one of these catecholamines. And this causes the following symptoms. Diarrheality, irritability, palpitations, and diaphoresis. These are from the epinephrine in the body. In our patient, the presentation of his decreased level of consciousness and the low blood sugar certainly seems to fit with hypoglycemia. Now who's at risk of getting hypoglycemic? There are four main broad categories. They include sepsis or infection, some problem with the endocrine system, fasting, and medications or toxins. We'll discuss each of them. First, sepsis. Sepsis cause hypoglycemia by two main mechanisms. It first inhibits gluconeogenesis. It also increases utilization of glucose in the periphery. You don't make enough and you use up what's already made and therefore as a result, your blood sugar drops. Next endocrinopathies. They include hypothyroidism, adrenal insufficiency, and really rare cause such as insuloma. So your body is basically producing way more insulin than you need. The third category is fasting. Usually the patient has run out of fuel and depends on the patient's reserves, sometimes a short fast can produce hypoglycemia in them. The cororary is patients who might be on a steady dose of medication that decrease their blood sugar even though they have not been fasting, if they have been exercising more than usual, that can also cause their glucose to fall. Finally, medications or toxins. This is a big and common category. We divide this up into two different parts. First medications which are designed to decrease blood sugar or hypoglycemic. These are medication a diabetic would be taking. However, if the patient has taken too much or taken at the wrong time or not in enough or exercised too much, that can result in hypoglycemia. These medications include sulfonylurea, such as galaburide, and various forms of insulin. There are also other less obvious drugs which will also decrease the patient's blood sugar. The main one is alcohol, since alcohol suppresses gluconeogenesis. Other medications include beta blockers and salicylates. Therefore, when you see a patient who have hypoglycemia once you've treated them, you really want to get the correct list of medication that they're on or any toxins they might be exposed to. How do we treat the patient with hypoglycemia? If we have no IV access, we can give 1 mg of glucagon intramuscularly. If we have IV access, we can give 1 amp of D50 in an adult. If the patient can take oral intake, we will feed them instead. We want to give them complex carbohydrates because they are better in maintaining glucose than just the 1 amp of D50. Examples such as sandwiches, banana, crackers, etc. If the patient is on a sulfonylurea, sometimes you may find that the blood sugar does not go up. We can give octreotide to reverse the sulfonylurea first. So back to our patient. Because he has a fairly decreased level of consciousness, we've decided that we cannot feed him. And we happen to have IV access, so we decided to give him 1 amp of D50 solution and he promptly wakes up. He is now able to answer your questions. What do you want to ask him? We want to ask those questions that we discussed before to find out if he has the four main causes of hypoglycemia. Such as whether he has an infection or sepsis, endocrinopathies, whether he has been fasting or doing a lot of exercise, whether he takes any medication regularly to decrease his blood sugar or has he been taking anything else. Once the sugar is normal, we will want to monitor it every hour until it's stabilized. We also would want to monitor his level of consciousness as well. If our patient has taken long-acting hypoglycemic medication, he might need longer monitoring or even an emission. In summary, we discussed the various symptoms hypoglycemic can produce. These patients all need a butt-side glucose. Remember oral intake is better than IV to sustain a normal blood sugar. This ends the segment on hypoglycemia and thank you for watching.