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Referral and warning signs
When to refer
Refer to HC4/Hospital if: Patient remains unconscious or confused despite glucose administration. Hypoglycaemia is severe or recurrent without obvious cause. Caused by long-acting insulin or oral hypoglycaemic agents (requires prolonged observation/admission). Suspected underlying cause requires hospital investigation (e.g., insulinoma, adrenal insufficiency).
Red flags
- Unconsciousness or coma
- Active seizures
- Persistent confusion or neurological deficit despite glucose correction
- Hypoglycaemia caused by long-acting insulin or sulphonylurea agent
- Recurrent episodes without clear explanation
- Inability to maintain safe glucose levels orally
Signs and symptoms
- Autonomic symptoms (early): Sweating (diaphoresis), Tremors, Palpitations, Anxiety, Nervousness, Hunger
- Neuroglycopenic symptoms (later/severe): Dizziness, Confusion, Difficulty concentrating, Weakness, Drowsiness, Behavioural changes, Blurred vision, Slurred speech, Headache, Seizures, Loss of consciousness (coma)
Risk factors
- Diabetes mellitus treatment (Insulin overdose, excessive dose of sulphonylureas, missed meals, excessive exercise)
- Severe Sepsis or critical illness
- Malaria (especially severe malaria, or due to quinine treatment)
- Severe malnutrition / Starvation
- Hepatic disease (liver failure)
- Renal failure
- Excessive alcohol intake (especially without food)
- Adrenal insufficiency (cortisol deficiency)
- Growth hormone deficiency
- Insulinoma (rare pancreatic tumour)
- Prematurity (infants)
- Post-gastrectomy (dumping syndrome)
Diagnosis
Clinical assessment
Suspicion based on presence of symptoms (autonomic or neuroglycopenic) in a patient with risk factors. Confirmation requires blood glucose measurement.
Investigations
- Point-of-care blood glucose measurement (fingerstick test). Confirmed if <3.0 mmol/L (55 mg/dl) with symptoms.
- Laboratory plasma glucose (more accurate).
- Further investigations to determine underlying cause if not obvious (e.g., investigations for sepsis, malaria test, liver function tests, cortisol level, insulin/C-peptide levels - usually hospital level).
Diagnostic criteria
Whipple's Triad is classically used: 1. Symptoms consistent with hypoglycaemia. 2. Low plasma glucose concentration measured at the time of symptoms. 3. Relief of symptoms after the glucose level is raised.
Management
Non-pharmacological management
- If patient is conscious, alert, and able to swallow safely:
- Give fast-acting oral carbohydrate: 15-20g of glucose (e.g., 3-4 glucose tablets, 1/2 cup fruit juice or sugary non-diet soda, 3 teaspoons or packets of sugar dissolved in water).
- Recheck blood glucose after 15 minutes.
- If still low, repeat oral glucose.
- Once glucose is >4.0 mmol/L, provide a snack containing complex carbohydrates and protein (e.g., bread, crackers with cheese, milk) to prevent recurrence, especially if next meal is >1 hour away or if caused by long-acting insulin/oral agent.
Pharmacological treatment
- If patient is unconscious, having seizures, or unable to swallow safely:
- Secure airway, breathing, circulation (ABC).
- Establish IV access.
- Adults: Give Glucose 50% 20-50 ml IV slowly (over 1-3 minutes). Flush line afterwards. Follow with Dextrose 10% IV infusion if needed until patient is fully conscious and able to eat.
- Children: Give Dextrose 10% IV 2-5 ml/kg bolus slowly. Follow with Dextrose 10% infusion if needed.
- If IV access cannot be obtained quickly: Glucagon 1 mg IM/SC (Adults/Children >25kg); 0.5mg (Children <25kg). Note: Glucagon may be ineffective in starvation, alcohol-induced hypoglycaemia, or adrenal insufficiency.
- Treat underlying cause (e.g., adjust diabetes medication, treat sepsis/malaria).
- Follow specific Ugandan treatment algorithms/guidelines.
Monitoring
Monitor blood glucose frequently (e.g., every 15-30 minutes initially, then hourly) until stable and patient is conscious and eating. Continue monitoring for several hours, especially if caused by long-acting insulin or oral hypoglycaemic agents (e.g., sulphonylureas - risk of recurrence is high, may require admission and prolonged infusion). Monitor neurological status.
Complications
- Seizures
- Permanent neurological damage (brain damage) if severe or prolonged
- Coma
- Cardiac arrhythmias
- Injury from falls or accidents during episode
- Death
Prevention
- Patient education (especially for diabetics) on recognizing early symptoms and self-treatment.
- Regular meals and snacks for those at risk (diabetics, post-gastrectomy).
- Appropriate dosing and timing of insulin and oral hypoglycaemic agents.
- Regular blood glucose monitoring for diabetics.
- Advise patients at risk to carry fast-acting glucose (tablets, gel, sugar packets) at all times.
- Advise diabetic patients to wear medical identification (bracelet/tag).
Patient education
- Teach patients (especially diabetics) and their families about symptoms of hypoglycaemia.
- Explain how to treat mild-moderate episodes with oral glucose.
- Explain when to seek emergency help.
- Discuss prevention strategies (meal timing, medication adherence, glucose monitoring).
- Importance of carrying fast-acting glucose and medical ID.
- How to use glucagon kit if prescribed.
Uganda-specific notes
Note preparation instructions for Dextrose 10% (from D5% and D50%). Always consider severe malaria and sepsis as potential causes of hypoglycaemia, especially in febrile patients with altered mental status. Quinine therapy for malaria can also induce hypoglycaemia.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 1, Section 1.1.6