Plasma glucose concentration is closely regulated by the autonomic nervous system. Glucagon promotes hepatic glycogenolysis and gluconeogenesis and is a hyperglycemic agent. Insulin promotes cellular glucose uptake and is a hypoglycemic agent. Hypoglycemia (Table 3) is defined as sustained plasma glucose level <70 mg/dL. Heavy exercise, anxiety, and infection may cause hypoglycemia, but the most common cause is treatment with insulin and/or oral hypoglycemic agents and inadequate carbohydrate intake (delayed, decreased, or missed meals).
Prevention:- Identify at-risk patient
- Confirm compliance with regimen of antidiabetic medications and food intake
- Reduce anxiety
- Ensure profound local anesthesia
- Use local anesthetic agents containing a vasoconstrictor congruent with the patient’s functional capacity
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Signs and symptoms:- Signs and symptoms start to develop at plasma glucose values <65 mg/dL
- Adrenergic manifestations
- Twitching, tremor
- Anxiety, nervousness
- Sweating, cold, clammy skin
- Pallor
- Mydriasis
- Glucagon manifestations
- Hunger
- Nausea, vomiting, abdominal discomfort
- Neuroglycopenic manifestations
- Fatigue, weakness, lethargy
- Paresthesia
- Flashes of light in the field of vision
- Headache
- Subtle reduction in mental capacity (plasma glucose level <65 mg/dL)
- Impairment of action and judgment (plasma glucose level <40 mg/dL)
- Focal or generalized seizure (plasma glucose level <30 mg/dL)
- Hypoglycemic coma (plasma glucose level <10 mg/dL)
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Emergency response:- Place patient in a semi-reclining position (supine if patient becomes unconscious)
- Mild hypoglycemia
- If the patient is conscious, able to follow commands, and can swallow safely administer oral glucose in the form of glucose tablets (if available) otherwise a glass of fruit juice or 3 tbsp of sugar with water are acceptable alternatives
- Severe hypoglycemia, i.e., loss of consciousness and/or seizure
- Notify EMS
- Apply a ribbon of sucrose paste (cake icing) on oral soft tissues or administer glucagon, 1 mg, IM or SL
- Administer oxygen
- 4 to 6 L/min by nasal cannula
- Monitor vital signs
- If at any time the patient becomes unresponsive, no normal breathing, and no palpable pulse consider the diagnosis of cardiac arrest
- Immediate CPR and defibrillation congruent with current recommendations
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Nota bene:- Signs of recovering: improved mental state
- Signs of deterioration: vital signs unstable, mental status labile
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