Altered Mental Status Answers 285This group includes sulfonylureas (glyburide, glipizide) and nonsulfonylurea
secretagogues (repaglinide, nateglinide). Other common causes of hypo-
glycemia are insulin overdose, alcohol abuse (inhibition of gluconeogenesis)
and sepsis. The presentation of a hypoglycemic patient generally involves
signs and symptoms of CNS dysfunction owing to the release of counterreg-
ulatory hormones secondary to the unavailability of glucose. Symptoms include
anxiety, diaphoresis, palpitations, and confusion. Don’t be fooled by improved
blood glucose levels after dextrose administration in overdose with oral hypo-
glycemic agents. Hypoglycemia can last more than 24 hours because of
long-lasting pancreatic effectsand will recur after dextrose infusion. Patients
need to be observed in the hospital with frequent bedside glucose checks. They
can be placed on a dextrose drip. Octreotide, an inhibitor of insulin release can
also be administered.
Choice(a)is inappropriate since hypoglycemia will recur after admin-
istration of a single bolus of dextrose. IV fluids and insulin (c)are treat-
ments for hyperglycemia. IV fluid without dextrose (d)is not helpful in
hypoglycemia management. Activated charcoal administration (e)is rec-
ommended within an hour after certain toxic ingestions or when there may
be a coingestion of an unknown toxin.
257.The answer is b. (Rosen, p 1260.) The patient has hepatic
encephalopathy, which is a clinical state of disordered cerebral function
occurring secondary to acute or chronic liver disease. Laboratory tests may be
normal in patients, but the serum ammonia level is usually elevated. Lac-
tulose and neomycinrepresent the main therapeutic agents. Lactulose is a
poorly absorbed sugar metabolized by colonic bacteria that traps ammonia
and helps excrete it in the stool. Neomycin is a poorly absorbed aminoglyco-
side that is believed to act by reducing colonic bacteria that are responsible for
producing ammonia. No other antibiotics (a, c, d,and e)are indicated in the
management of hepatic encephalopathy.
258.The answer is b.(Rosen, pp 1445-1455.)Generally, the first-line
pharmacologic treatment in an actively seizing patient is a parental
benzodiazepine,such as diazepam (Valium), lorazepam (Ativan), or mida-
zolam (Versed). Benzodiazepines are effective in terminating ictal activity in
75% to 90% of patients. Diazepam can be administered intravenously,
intramuscularly, or down an endotracheal tube. Lorazepam and midazolam
can be given intravenously or intramuscularly. All three have similar efficacy
in terminating seizures.