Several features make sorting through the differential diagnosis challenging to the emergency physician. The term low blood sugar is often used frivolously to describe a range of symptoms that may or may not be related to a low plasma glucose concentration. Refer to  Blood Sugar Levels for Diabetes and Impaired Glucose Tolerance (high readings) for more information. There are are also general and non-specific signs and symptoms which should not be used in isolation to diagnose hypoglycemia.
As the blood glucose levels continue to drop without any intervention, the glucose supply to the brain is severely impaired and may result in the symptoms listed below.
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There is also confusion relating to the blood glucose levels that can be classified as hypoglycemia.
This triggers certain processes like releasing the glucose stored in the liver (glycogen) in an attempt to stabilize the blood glucose levels. In patients who experience frequent episodes of hypoglycemia, the body may stop releasing epinephrine. Changes in behavior at this stage may resemble inebriation (alcohol intoxication, drunkenness) and is sometimes mistaken for alcohol dementia in alcoholics.
Many times, the exact etiology will not be determined in the ED, and a generalized approach is appropriate.
This is known as hypoglycemic-associated autonomic failure (HAAF) or is also referred to as hypoglycemia unawareness.
The blood glucose levels continue to drop until the neuroglycopenic symptoms may be evident.


A recent study suggests that purulent tracheal exudates are more likely in somewhat older, less-sick school-age children who may not require intubation.34 Bacterial infection of the trachea can lead to profound respiratory distress, with upper airway stridor, high fever, and a productive cough. Croup, usually due to parainfluenza virus, is characteristically a relatively mild outpatient disease, but it occasionally may present with severe respiratory distress or failure. These children tend to have copious rhinorrhea in association with an antecedent upper respiratory tract infection. Critically illinfants with bronchiolitis can become dehydrated from insensible losses and decreased fluid intake.
In one review involving 580,000 pediatric ED visits, there were only 320 cases of cardiac arrhythmias, half of which were sinus tachycardia and 13% of which were supraventricular tachycardia.11 Supraventricular tachycardia is an important cause of cardiogenic shock in infants. With reentrant tachycardia, an infant?s heart rate may reach as high as 300 beats per minute. At that rate, there is little time for the heart to fill during diastole.MyocarditisMyocarditis is the most common acquired cause of cardiomyopathy and heart failure in children and is usually due to a viral infection of the heart. A murmur may or may not be appreciated.Genitourinary CausesInfants can develop renal failure and altered mental status if they have congenital genitourinary abnormalities. One retrospective chart review examined 120 patients 5 years of age or younger who required an operation for appendicitis.42 All 10 of the children under the age of 1 year had perforated their appendix at the time of surgery. Although well-described in the literature, it is not clear why intussusception causes altered mental status.44-46 While the supposedly classic ?currant jelly? stool is seen in a small minority of cases,47 heme-positive stools are common. The largest study on midgut volvulus showed that over half of the patients presented during the first 30 days of life.6 Bilious vomiting was seen in all of the patients with midgut volvulus.
Under physiologic stress, such as infection or dehydration, cortisol deficiency leads to hypoglycemia.51 Acute saltwasting crisis typically presents in infants 2-5 weeks of age. The initial symptoms are nonspecific, such as poor feeding, vomiting, inadequate weight gain, and irritability. Idiopathic ketotic hypoglycemia is typically associated with fasting due to vomiting and diarrhea in previously healthy toddlers and preschoolers.


Young children who accidentally ingest (or are intentionally given) alcohol will also develop low blood sugars. It is crucial to remember that hypoglycemia is common in critical illnesses from a variety of causes.
In one study, nine of 49 children (18%) requiring resuscitation in the ED had associated hypoglycemia.53Diabetic KetoacidosisDiabetic ketoacidosis can produce shock from both fluid losses and electrolyte abnormalities. One study reviewed all deaths in the United Kingdom for individuals under 20 years of age who had diabetes listed on the death certificate.
Of 116 deaths, 69 were attributable to diabetic ketoacidosis and seven to hypoglycemia.54Neurologic CausesNeurologic causes of the acutely ill appearance or comatose state include acute hydrocephalus, central nervous system tumor, ventriculoperitoneal (VP) shunt malfunction or infection, rupture of an arteriovenous malformation, and nonconvulsive status epilepticus. Vomiting, depressed mental status, and a focal neurologic examination are common in these conditions.Nonconvulsive status epilepticus can produce coma or altered mental status. It can be difficult to diagnose, as the child has no abnormal motor activity; the diagnosis can be confirmed only on electroencephalogram. The prevalence of nonconvulsive status epilepticus in children remains unknown.55,56Traumatic CausesNon-accidental trauma may present in a variety of ways, many of which are subtle.
Bruising, a suspicious story, a bulging fontanelle, and retinal hemorrhages are characteristic.Toxicologic CausesThe evidence regarding toxicologic causes primarily consists of case reports and case series. After the child begins to crawl at 6 or 7 months, accidental ingestions become more common.



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