UCONN Emergency Medicine Interest Group

Posts Tagged ‘neurology’

Pearl/Pitfall: Hypoglycemia

In PEARL/PITFALL on July 25, 2011 at 2:15 PM

Based on two discussions I had with Dr. Nowicki and Dr. Price:

Always check a blood glucose level in patients with altered mental status or neurologic deficits. The clinical presentations of hypoglycemia are protean; Dr. Nowicki told me about a case in which a patient presented with an isolated unilateral CN VII palsy in a patient with no prior neurologic history, which completely resolved after the hypoglycemia was corrected. It is both embarassing to the provider as well as potentially dangerous for the patient for delay in diagnosis of this condition. It is very simple and fast for this to be ruled out as a likely cause of the patient’s symptoms, and the stakes are high. However, there are several things that should be considered as pitfalls here.

First, the blood glucose level at which nondiabetic patients and diabetic patients display symptoms may differ considerably. In one study in NEJM (reference provided below), poorly controlled diabetics first developed symptoms at a mean glucose of 78 mg/dL, while nondiabetics developed symptoms at a mean glucose of 53 mg/dL. The implication is that a so-called “normal” glucose level, which may not be flagged as abnormal by the lab (which has no knowledge of the patient’s history) may actually be hypoglycemic in terms of their body’s altered metabolism.

Second, it is important not to undertreat hypoglycemia. The initial treatment, of course, is IV dextrose; adult patients typically require 0.5-1.0 g/kg D50. Since an amp of D50 has 25 g of dextrose, a single amp of D50 will usually not be sufficient to match this requirement (consider that the “standard” patient is 70 kg; this implies that they will need at minimum 35 g, and up to 70 g of dextrose, which implies they will need at least 2 and potentially 3 amps). Once the patient is able, this initial bolus of dextrose should then be followed by a meal; this provides sustained calories over time (if the patient cannot eat, dextrose infusions may be necessary). Otherwise, the patient may rebound back into hypoglycemia!

References:

Boyle PJ, Schwartz NS, Shah SD, et al. Plasma glucose concentrations at the onset of hypoglycemic symptoms in patients with poorly controlled diabetes and in nondiabetics. N Engl J Med. 1988;318:1487-1492.

Journal Article Synopsis: Is ED Hyperglycemia a Poor Prognostic Marker in Intracerebral Hemorrhage?

In JOURNAL CLUB on July 11, 2011 at 3:21 PM

Summary of “Emergency Department Hyperglycemia as a Predictor of Early Mortality and Worse Functional Outcome after Intracerebral Hemorrhage” By Latha G Stead et al, Neurocritical Care vol 13: pp. 67-74. 2010.

What is already known on this topic:
Hyperglycemia upon admission was already known to be a predictor for poor outcome in ischemic stroke. A relationship between hyperglycemia and mortality in intracerebral hemorrhage (ICH) had been suggested, but little data was present to define its prognostic ability.

What question this study addressed:
Is hyperglycemia at arrival associated with early mortality and functional outcome in patients with non-traumatic ICH?

What was the study design:
A prospective, cohort study of 237 adults presenting to the ED with CT confirmed, spontaneous ICH between 1/06 to 12/08, with a blood glucose measurement at presentation. Data was collected by two independent, blinded abstractors.

What this study adds to our knowledge:
This study showed that hyperglycemia (defined as blood glucose of ≥140) in both diabetic and non-diabetic patients is a prognostic predictor of higher mortality within 7 days. Among non-diabetics, it is also a predictor of poor clinical outcome  when controlled for stroke severity, age, and volume of hemorrhage. Furthermore, higher blood glucose values correlated with more severe stroke, measured by the NIH Stroke Scale. There was no significant difference shown among diabetic patients when glucose levels were used as a predictor for poor clinical outcome or stroke severity.

How is this relevant to clinical practice:
This study allows confirms that hyperglycemia is a red flag among patients presenting to the Emergency Department with ICH and gives clinicians an early, easily obtained prognostic indicator for mortality and outcome in these patients.

Other considerations:
Further research can be done to see if control of hyperglycemia may lead to better outcomes among ICH patients. This study is limited in its design- it only considered outcome at the end of the hospital stay, but did not control for the length of stay. More research should be done to determine if there is a difference in outcome at  specific time points over a greater length of time (eg. 3, 6, and 12 months).

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