Rosen & Barkin's 5-Minute Emergency Medicine Consult (379 page)

• Neonatal hypoglycemia may occur after maternal use of sulfonylureas during labor
  
• Ingestion of 1 sulfonylurea tablet may cause hypoglycemia in a child:
  
  • Death has been reported after ingestion of a single tablet
    
• Onset of symptomatic hypoglycemia may be delayed up to 8 hr
  

• Diagnosis of diabetes in patient
  
• Access to diabetic medications:
  
  • If occurring in a medical setting (hospital, nursing home), consider:
    
    • Dosing error
      
    • Malicious intent
      

• Vital signs:
  
  • Tachycardia (may be blunted if on β-blockers)
    
• Neurologic:
  
  • Confusion, obtundation, coma
    
  • Ataxia, other cerebellar signs
    

• Diagnosis based on clinical presentation and an accurate history
  
• Monitor serum glucose concentration
  
• Monitor vital signs and neurologic status
  
• Obtain serum electrolytes and lactate for biguanide ingestion
  
• Obtain liver function tests for thiazolidinedione ingestion
  

• Serum glucose before and after treatment
  
• Electrolytes:
  
  • Check for hypokalemia
    
  • Anion gap acidosis
    
• BUN, creatinine:
  
  • May reveal renal insufficiency, causing drug accumulation
    
• CBC
  
• Ethanol level
  
• Lactate level (especially if biguanide medications involved)
  
• Liver function tests
  
• Arterial blood gas
  
• Assays for immunoreactive insulin and C-peptide levels:
  
  • Confirms administration of exogenous insulin if insulin level is high and C-peptide is low in the setting of hypoglycemia
    
  • Do not correlate with severity of clinical symptoms
    

• ECG: Sinus tachycardia, premature ventricular contractions (PVCs), atrial dysrhythmias
  
• EEG: Diffuse slowing without focal abnormalities
  
• CT scan: Cerebral edema if prolonged hypoglycemia
  
• Chest radiograph: Aspiration pneumonia or pulmonary edema
  

• Addison disease
  
• Panhypopituitarism
  
• Sepsis
  
• Insulinoma
  
• Neuroendocrine tumors
  
• Cirrhosis
  
• Chronic ethanol abuse
  
• Ethanol ingestion
  
• Salicylate ingestion
  
• β-antagonist ingestion
  
• Ackee fruit poisoning
  

TREATMENT

Transport all medications, pills, and pill bottles involved in overdose for identification in ED

• ABCs:
  
  • Airway control essential
    
  • Administer supplemental oxygen
    
  • IV access
    
  • Cardiac monitor and pulse oximetry
    
• Naloxone, thiamine, D
  ₅₀
  (or Accu-Chek) if altered mental status
  

• Hypoglycemia:
  
  • D
    ₅₀
    bolus, then:
    
    • IV infusion D
      ₅
      W or D
      ₁₀
      W to maintain euglycemia or mild hyperglycemia
      
    • Food (if mental status improves or normalizes)
      
• Neuroglycopenia:
  
  • May persist shortly after serum glucose corrected
    
  • Persistent symptoms require further dextrose administration
    
• Decontamination:
  
  • Consider administration of activated charcoal for recent or large ingestion of oral agent (sulfonylurea or biguanide)
    
• Provide supportive care
  
• Hypotension:
  
  • 0.9% NS IV fluid bolus
    
  • Pressor support with dopamine or norepinephrine as needed:
    
    • Pressors may increase lactate production
      
    • Use cautiously with biguanide-induced lactic acidosis
      
• Administer sodium bicarbonate for biguanide-induced lactic acidosis if pH < 7
  
• Administer benzodiazepines for seizures
  
• Inhibit insulin secretion for sulfonylurea overdose with recurrent hypoglycemia with:
  
  • Octreotide
    
  • Diazoxide (watch for hypotension)
    
• Early hemodialysis may be beneficial in cases of biguanide-induced lactic acidosis:
  
  • Corrects acid–base abnormalities
    
  • Enhances elimination of the drug
    

• Activated charcoal: 1 g/kg PO
  
• Dextrose: 50–100 mL D
  ₅₀
  (peds: 2 mL/kg of D
  ₂₅
  over 1 min) IV; repeat if necessary
  
• Diazepam: 5–10 mg (peds: 0.2–0.5 mg/kg) IV q10–15min
  
• Diazoxide: 200 mg PO or 1–3 mg/kg IV (infant: 8–15 mg/kg/24 h q8–12hPO/IV; child: 3–8 mg/kg/24 h q8h PO/IV)
  
• Glucagon: 1–2 mg (peds: 0.03–0.1 mg/kg) IM/SC/IV
  
• Lorazepam: 2–4 mg (peds: 0.03–0.05 mg/kg) IV q10–15min
  
• Octreotide: 50–100 μg q8–12h SC/IV
  
• Thiamine (vitamin B
  ₁
  ): 100 mg (peds: 50 mg) IV or IM
  

FOLLOW-UP

• Hypoglycemia owing to sulfonylurea agents (may require several days of monitoring) or long-acting insulin preparations
  
• Any patient requiring a constant infusion of dextrose to maintain euglycemia
  
• Intentional overdose or self-injection of insulin warrants admission for 24 hr glucose monitoring
  
• All children with accidental ingestion of sulfonylureas
  
• Metabolic alterations owing to biguanide ingestion or accumulation
  

• Accidental hypoglycemia owing to short-acting insulin injection in the setting of dietary insufficiency:
  
  • Must be tolerating oral intake
    
  • Ensure return to baseline mental status
    
• Discharge after glucose correction and a 4 hr period of observation
  

• Patients with unintentional (accidental) poisoning require poison prevention counseling
  
• Patients with intentional (e.g., suicide) poisoning require psychiatric evaluation
  

Close primary care follow-up to help monitor blood sugar and adjust medication dosages

• Sulfonylureas can have markedly prolonged half-lives and long elimination times:
  
  • Delayed hypoglycemia and refractory hypoglycemia are common
    
  • Admit for observation, at a minimum
    
• Metformin must be held for 48 hr after any study requiring IV contrast media:
  
  • IV contrast can prolong renal clearance of biguanides
    
  • Can induce metformin-associated lactic acidosis
    

• Bosse GM. Chapter 48. Antidiabetics and hypoglycemics. In: Hoffman RS, Nelson LS, Goldfrank LR, et al., eds.
  Goldfrank’s Toxicologic Emergencies
  . 9th ed. New York, NY: McGraw-Hill; 2011.
  
• Dougherty PP, Klein-Schwartz W. Octreotide’s role in the management of sulfonylurea-induced hypoglycemia.
  J Med Toxicol
  . 2010;6(2):199–206.
  
• Glatstein M, Scolnik D, Bentur Y. Octreotide for the treatment of sulfonylurea poisoning.
  Clin Toxicol (Phila)
  . 2012;50(9):795–804.
  
• Kopek KT, Kowalski MJ. Metformin-associated lactic acidosis (MALA): Case files of the Einstein Medical Center medical toxicology fellowship.
  J Med Toxicol
  . 2013;9(1):61–66.
  
• Kruse JA. Metformin-associated lactic acidosis.
  J Emerg Med
  . 2001;20(3):267–272.
  
• Little GL, Boniface KS. Are one or two dangerous? Sulfonylurea exposure in toddlers.
  J Emerg Med
  . 2005;28(3):305–310.
  
• Rowden AK, Fasano CJ. Emergency management of oral hypoglycemic drug toxicity.
  Emerg Med Clin North Am
  . 2007;25:347–356.
  

See Also (Topic, Algorithm, Electronic Media Element)

Hypoglycemia

CODES

962.3 Poisoning by insulins and antidiabetic agents

BASICS