Signs and Symptoms
Autonomic features (warning signs):
sweating, hunger, tingling around the mouth
tremor, tachycardia, pallor, palpitations and anxiety.
These warning signs may be lost in patients with repeated or prolonged hypoglycaemia.
Lethargy, tiredness, change in behaviour
Headache, visual disturbance, slurred speech, dizziness.
Altered level of conscious, coma, convulsions.
Causes of Hypoglycaemia
High sugar requirement
Inborn errors of metabolism
Early manifestation of other serious disorders (sepsis, congenital heart disease, inter - cranial event).
Gastroenteritis - (rare in children <5 so shouldn't be routinely analyzed at triage)
Ketotic hypoglycaemia - toddlers with lethargy or seizure following a prolonged fast. May be unresponsive in the morning.
Bloods for analysis
Oral carbohydrate challenge - unless child too unwell for this. The BNF is fantastic at recommended non pharmacological treatments first. Don't give dextrogel/ glucogel - coke, lucozade, sugar cubes, jelly babies work a lot better. Most diabetics I know would do anything NOT to have glucogel as it tastes so disgusting! Even the BNF doesn't advise it!
Bolus of IV glucose:
EPLS dose is 5-10ml/kg 10% dextrose and 2.5ml/kg in the newborn.
APLS has changed to 2ml/kg.
If no IV access available, give IM glucagon 0.5mg < 8 years, 1mg >8 years
IV infusion of 10% dextrose at 6-8mg/kg/min) to maintain sugar >4mmol/L
Critical Blood samples
Should only be taken during hypoglycaemia (BSL <2.6mmol/l)
- Glucose and lactate: fluoride oxalate tube
- Insulin, C-peptide, cortisol, growth hormone: plain tube on ice
- Ammonia: heparinized tube on ice
- Ketones and free fatty acids: fluoride oxalate (BLF) tube
(Do also bedside test ketones)
- Amino acids, electrolytes: heparinised
- Acid-base: capillary sample
- Blood drops onto a Guthrie test card (for acyl-carnitine profile)
- Others if required e.g. Toxicology studies (Salicylates, ethanol, sulfonylurea )
- Urine for ketones, glucose, reducing substances, amino acids, organic acids and maybe toxicology.
And here's my summary card, lest I ever forget which tubes to fill!