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Fluid replacement is the main 1st treatment in DKA so hartmans or saline is also correct
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This is hypoglycaemia not DKA..
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Tachycardia Outpatient
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Giggy G
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Why can you not give glucagon

16699
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because the question states that an IV line is in situ so its preferred

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Serpiginous Serotonin
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I made the same rookie error and gave IM glucagon 
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Axillary Dominant
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Endoscope Dorsal
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# Summary
 
Hypoglycaemia refers to low blood glucose levels, usually defined as <3.5 mmol/L. It may present with shaking, sweating, palpitations, hunger, headache, double vision, difficulty concentrating, slurred speech, confusion, and coma. After checking a capillary blood glucose, emergency management involves giving fast-acting carbohydrates then rechecking blood glucose in 10-15 minutes. For patients who are unable to swallow, intravenous dextrose or intramuscular glucagon should be given. Once they have improved, ensure they eat something with a long-acting carbohydrate to prevent recurrence of hypoglycaemia. 
 
# Definition
 
Hypoglycaemia is defined as a low blood glucose level, usually below 3.5 mmol/L.

Whipple's triad refers to:

- A low blood glucose level
- Symptoms or signs of hypoglycaemia
- Resolution of symptoms/signs once blood glucose normalises
 
# Aetiology
 
Hypoglycaemia is uncommon in patients who do not have diabetes - triggering factors include:

- Alcohol
- Insulin
- Oral hypoglycaemic medications such as sulphonylureas
- Decreased oral intake
- Excessive exercise

Rarer causes include:

- Insulinomas
- Adrenal insufficiency
- Reactive hypoglycaemia (e.g. after upper gastrointestinal surgery)
- Self-induced hypoglycaemia

# Signs and Symptoms
 
- Hunger
- Anxiety/irritability
- Tremor
- Sweating
- Headache
- Double vision
- Slurred speech
- Confusion
- Decreased level of consciousness
 
# Investigations
 
In the emergency setting, the main investigation is a capillary blood glucose (glucose may also be obtained from a blood gas).

Blood and urine assays for sulphonylureas can be used if their abuse is suspected (in the context of suspected self-induced hypoglycaemia).

In unexplained hypoglycaemia, further investigations may be indicated (e.g. serum insulin, C-peptide and proinsulin testing to differentiate between endogenous and exogenous insulin, early morning cortisol) - these are covered in more detail in the endocrinology chapter.

# Management
 
**In patients who are conscious and able to swallow:**

 - Give 15-20g of fast-acting carbohydrate (e.g. 5 glucose tablets or 200ml of fruit juice)
 - Avoid chocolate and biscuits as their fat content may delay stomach emptying
 - Glucose 40% gel may be useful in patients who are able to swallow but are confused or unable to cooperate
 - Recheck blood glucose in 10-15 minutes, and repeat the fast-acting carbohydrate if still less than 4.0
 - Once blood glucose is over 4.0, give a long-acting carbohydrate (e.g. a meal containing potato or pasta, or a snack with biscuits or toast) to prevent recurrence of hypoglycaemia
 
**In patients who are unconscious or unable to swallow:**

- Take an A-E approach and consider if airway protection required
- Administer 100ml of 20% glucose or 200ml of 10% glucose intravenously
- In patients with no IV access, give 1mg of glucagon intramuscularly (this acts to mobilise glycogen from the liver and so is less effective in cirrhosis, malnourished patients, alcohol excess and sulphonylurea treatment)
- Once blood glucose is over 4.0 and the patient has recovered, give a long-acting carbohydrate as above

**For all patients:**

- Review medications; may require adjustment of hypoglycaemic medications such as insulin or sulphonylureas
- Ensure regular capillary blood glucose monitoring for at least 24-48 hours
- Educate patients and families or symptoms of hypoglycaemia, how to self-monitor if appropriate and emergency treatment at home

# NICE Guidelines

[NICE CKS - Hypoglycaemia in Type 2 Diabetes](https://cks.nice.org.uk/topics/insulin-therapy-in-type-2-diabetes/management/insulin-therapy-type-2-diabetes/#hypoglycaemia)
 
# References

[Patient UK - Hypoglycaemia](https://patient.info/doctor/hypoglycaemia)
 
[Diabetes UK - Hypoglycaemia Guidelines](https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Archive/JBDS_01_HypoGuideline_4th_edition_FINAL_Archive.pdf)
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Emergency management of hypoglycaemia
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# Drug choice feedback

This patient is suffering from hypoglycaemia and the intravenous fluid required urgently is glucose. Glucose 10% or 20% are the most appropriate. The next higher concentration is Glucose 50%, a possible alternative, but due to its high concentration, it can extravasate and is an irritant. Hence, it is not preferred. The next lower concentration is Glucose 5%, which is too low for any clinical effect unless a large volume is administered which is impractical.

# Dose/Route/Frequency/Duration feedback

A dose of 15g-20g of glucose needs to be administered, hence as long as the volume of a particular intravenous glucose concentration given achieves this dose, as stated above, it is acceptable. The duration of administration should not exceed 15 minutes, so that the hypoglycaemic episode is not unduly prolonged.
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200 mL
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glucose 10% solution
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15m
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once only (STAT)
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intravenous (IV)
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100 mL
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glucose 20% solution
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15m
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once only (STAT)
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intravenous (IV)
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150 mL
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glucose 10% solution
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15m
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once only (STAT)
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intravenous (IV)
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75 mL
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glucose 10% solution
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15m
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once only (STAT)
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intravenous (IV)
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150 mL
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glucose 20% solution
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15m
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once only (STAT)
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intravenous (IV)
Case Presentation: A 24-year-old gentleman was found collapsed on the street and was brought to the Emergency Department.




## PH


Type 1 Diabetes Mellitus


## DH


Insulin Glargine (Lantus) 18 units, Insulin Aspart (Novorapid) 6 units at mealtimes


## On examination


Appears sweaty, drowsy, not oriented to time and place. Tremor noted in hands bilaterally. Cannula is in situ.


Temperature 36.7°C, HR 117, RR 25, BP 123/80, O2 97% RA, GCS 11, Weight 72kg


## Investigations


BM: 2.1 mmol/L (normal range 3.5-5.5 mmol/L)


TFT: Normal


ECG: Sinus Tachycardia


# Prescribing Request


Write a prescription for one intravenous drug that is most appropriate for treating his current condition.