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).

Table 3. Hypoglycemia.

  • 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
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, vomitting, 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)
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
      • Activate 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
Nota bene:
  • Signs of recovering: improved mental state
  • Signs of deterioration: vital signs unstable, mental status labile