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Acute Hypoglycemic Shock

Acute Hypoglycemic Shock

Medical Emergencies

Hypoglycemia is the most commonly encountered complication of diabetes.

Hypoglycemia occurs when blood glucose level falls below 50 mg/dL in adults and 40 mg/dL in children. However, hypoglycaemic reactions may occur in individuals with normal or higher than normal blood glucose levels.

Pathophysiology

Approximately, 70% of cases of non-diabetic hypoglycemia are caused by functional hyperinsulinism (related to an over secretion of insulin by pancreatic beta cells, due to increase insulin requirements).

Clinical Manifestations

  • Mild (initial symptoms)

    • Diminished cerebral function : Inability to perform simple calculations, decreased spontaneity of conversation, and mood change (eg. lethargy).
    • CNS involvement : Hunger, nausea, and an increase in gastric motility.
    • Weakness.

  • Moderate (sympathetic hyperactivity)

    • Increased anxiety, sweating and piloerection.
    • Tachycardia.
    • Cold and wet skin. (Hyperglycaemia - hot, dry skin).
    • Individual is conscious but may exhibit bizarre behavioural patterns such as confusion and uncooperativeness.

  • Severe (further drop in blood glucose levels)

    • Hypotension.
    • Loss of consciousness.
    • Seizures.

Diagnostic clues

  • Weakness, dizziness.
  • Pale, moist skin.
  • Normal or depressed respirations.
  • Headache.
  • Altered level of consciousness.

Management

The method of management depends on the patient's level of consciousness.

Conscious patient

  1. Terminate all dental treatment.

  2. Place the patient in a comfortable position. In most situations, the patient prefers to sit upright.

  3. Assess circulation, airway and breathing.

  4. Administer oral carbohydrates

    • If the patient is conscious and cooperative, oral carbohydrates such as sugar, orange juice, soft drinks and candy bars are the treatment of choice.
    • The carbohydrate should be administered in 3- or 4 ounce doses every 5-10 minutes until symptoms disappear.

  5. Once the patient recovers,

    • Observe for approximately 1 hour before discharging the patient.
    • Arrangements should be made for a responsible adult to escort the patient home.

If the patient does not respond to oral glucose or cooperate in ingesting,

  1. Call for medical assistance.

  2. Administer parenteral carbohydrates

    • Glucagon (1 mg) may be administered IM or IV (patient usually responds within 10-15 minutes), or,
    • 50 mL of a 50% dextrose solution may be administered IV over 2-3 minutes (patient usually responds within 5 minutes).

  3. Oral carbohydrates should be started as soon as tolerated by the patient.

  4. Monitor vital signs every 5 minutes.

  5. Shift to a hospital for evaluation and any further management required.

Unconscious patient

  1. Terminate all dental treatment.

  2. Place the patient in supine position with legs elevated slightly.

  3. Assess circulation, airway and breathing and start BLS, as needed. Usually circulation is adequate and breathing is spontaneous, and the patient requires only airway management.

  4. Call for medical assistance.

  5. Administer carbohydrates :

    • 50% dextrose solution IV or glucagon (1 mg) IM or IV.
    • Oral administration : Any liquid or other substance such as gel or paste (that can liquefy at body temperature) should never be given to an unconscious patient orally : The substance might run down into the throat and increase the possibility of aspiration or airway obstruction.

  6. If neither glucagon nor a 50% dextrose solution is available, 0.5 mg of a 1:1000 epinephrine concentration may be administered via the subcutaneous or IM route and repeated every 15 minutes as needed.

  7. Severe hypoglycemia may be associated with the development of generalised tonic-clonic seizures : Managed same as other seizures. (*Seizures induced by hypoglycemia may persist until the blood glucose levels increases).

  8. Shift the patient to a hospital for definitive care and observation.

References

  • Medical Emergencies in the Dental Practice (7th edition), Stanley F. Malamed, Daniel L Orr II, Mosby Elsevier.
  • Contemporary Oral and Maxillofacial Surgery (6th edition), James R Hupp, Edward Ellis III, Myron R Tucker, Mosby Elsevier.

*This article is an excerpt from the above mentioned books and Medical Sutras does not make any ownership or affiliation claims.