Hypoglycemic event in a known diabetic not on Sulfonylureas: Any work up needed?

[Angry Birds]

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Patient has low BG, gets glucose, and BG is now normal.
Any work up needed?

Just treat and street?

On that note, what are you guys doing with heroin overdoses who fully respond to narcan? Treat and street as well? Any observation period required as long as no oral opiates involved?

 

[BoardingDoc]

Patient has low BG, gets glucose, and BG is now normal.
Any work up needed?

Just treat and street?

On that note, what are you guys doing with heroin overdoses who fully respond to narcan? Treat and street as well? Any observation period required as long as no oral opiates involved?

The pts with DM and low BG frequently get basic labs and a UA if they're old to make sure that they don't have some underlying process causing their BG to drop. The younger ones who can clearly state "I took my insulin and then didn't eat anything for 3 hours" can go home after a sandwich and 2 FSBGs that are normal/stable roughly 30 min apart.

As for the opioids, I don't care if they have orals onboard. They get 1-2 hrs obs depending on when they got narcaned. Home if still alert/awake after the narcan wears off. If they want to leave before then, that's fine as long as they aren't clinically intoxicated again, they just go AMA.

 

[Angry Birds]

The pts with DM and low BG frequently get basic labs and a UA if they're old to make sure that they don't have some underlying process causing their BG to drop. The younger ones who can clearly state "I took my insulin and then didn't eat anything for 3 hours" can go home after a sandwich and 2 FSBGs that are normal/stable roughly 30 min apart.

As for the opioids, I don't care if they have orals onboard. They get 1-2 hrs obs depending on when they got narcaned. Home if still alert/awake after the narcan wears off. If they want to leave before then, that's fine as long as they aren't clinically intoxicated again, they just go AMA.

Great algorithm. I’m gonna steal it.

 

[shookwell]

Patient has low BG, gets glucose, and BG is now normal.
Any work up needed?

Just treat and street?

On that note, what are you guys doing with heroin overdoses who fully respond to narcan? Treat and street as well? Any observation period required as long as no oral opiates involved?

If there's no clear reason why they got hypoglycemic (forgot to eat, etc.) and they're on insulin, then I will check a creatinine.

 

[gro2001]

Agree with above. UA and Cr unless obvious reason for hypoglycemia (ie breakfastopenia). Although older patients get those even if there is an obvious reason. They can be sneaky that way.

From the orals I would only really observe longer for the long acting PO opioids like methadone.

 

[BoardingDoc]

Agree with above. UA and Cr unless obvious reason for hypoglycemia (ie breakfastopenia). Although older patients get those even if there is an obvious reason. They can be sneaky that way.

From the orals I would only really observe longer for the long acting PO opioids like methadone.

even if it's methadone, who cares? Wait 2 hrs if you're concerned so you know you've covered narcan's half-life. If they're going to be intoxicated again at that point, they'll be intoxicated. If they aren't, send em home.

 

[gro2001]

even if it's methadone, who cares? Wait 2 hrs if you're concerned so you know you've covered narcan's half-life. If they're going to be intoxicated again at that point, they'll be intoxicated. If they aren't, send em home.

Yeah, a lot of this may be driven by latent indoctrination from residency.

 

[Groove]

Just remember methadone takes 2.5-4 hours to peak. If they ate some prior to shooting up heroin and were reversed with narcan, observed for 1.5 hours and were drowsy, but NAD, VSS, ambulatory, they can easily go into respiratory distress again if you boot them out too early. Luckily, I don't have too much methadone heroin abusers unless they just aren't telling me, which is distinctly possible.

In general, I obs the heroin overdoses for 2 hours and I would say...roughly 50% of mine have left AMA within that timeframe. "I got things to do doc! I feel fine! Can I be honest with you doc? I gotta go buy some more heroin!" Oxycodone or other orals don't bother me as much as methadone because they peak after an hour, so after 2 hours the narcan is obviously long gone and if they are going to have any respiratory distress, they should have had it by then. Most go home. If at any point they require repeat dosing of narcan or have abnormal RR, O2, they get admitted to obs or they sign out AMA. Luckily, I don't have hospitalists who give me grief over these soft admits. I just don't tolerate observing these people for 6 and 8 hours in the ED. Ridiculous.

 

[thegenius]

Patient has low BG, gets glucose, and BG is now normal.
Any work up needed?

Just treat and street?

On that note, what are you guys doing with heroin overdoses who fully respond to narcan? Treat and street as well? Any observation period required as long as no oral opiates involved?

Regarding the hypoglycemia...would need more information before rendering a treatment recommendation. Everything written above is acceptable in select cases. From doing nothing and d/c to labs/UA and observation in the ED making sure they don't remain hypoglycemic. For what it's worth, my Dad is an endocrinologist and he can't remember the last time he sent someone to the ED to took too much insulin by accident. He would tell them to stay at home, check their blood sugars q1-2 hrs, and eat frequently

Regarding heroin...funny I rarely get that where I work in Northern CA. Get lots and lots of meth. If a guy came in hypopneic with pinpoint pupils, only responsive to noxious stimuli, etc....I would certainly not d/c after narcan and 30-60 mins obs....just as a matter of principle. Lots of these guys take multiple drugs and just realistically speaking they get watched for 2-3 hours minimum. Can't trust the drug addicts! LOL