Special Operations Forces Medical Handbook

4-31

Assessment: Always consider hypoglycemia as an easily treatable form of mental status
impairment. ALWAYS check for it in patients presenting with coma, seizure, confusion or focal
neurologic signs.

Differential Diagnosis - drug overdose with sedative or narcotic agents, alcohol intoxication, idiopathic
seizure disorder, closed head trauma, CNS infection (meningitis, encephalitis), and a variety of metabolic
insults (uremia, metabolic alkalosis, respiratory acidosis or severe hyponatremia) can all produce severe
confusion or coma and cannot be visually distinguished from hypoglycemia. At times hypoglycemia can
provoke focal neurologic signs such as hemiparesis which reverse with treatment of hypoglycemia.

Plan:

Treatment
Primary: One ampule of 50% dextrose (D50%) should be injected IV push, rapidly.
Alternative: Mild symptoms and cooperative: 8 oz of sweetened fruit juice, non-diet colas or sports drink
(i.e., Gatorade).
Empiric: 1 amp of D50% rapid IV push for any form of mental status impairment when blood glucose
testing is unavailable.
Emergent: Glucagon 1 mg may be reconstituted (comes as two vials, which must be combined) and injected
intramuscularly if IV access is difficult or impossible.

Patient Education
General: Wear a medical alert bracelet or necklace if prone to hypoglycemia.
Activity: Except as noted, normal unrestricted activity is permitted.
Diet: Normal diet unless frequent hypoglycemia, then add mid-morning, mid-afternoon, and bedtime snacks.
Medications: Patients who had coma, seizure or focal neurologic signs need glucagon 1 mg for IM self-
injection.
Prevention and Hygiene: Do not miss meals or exercise strenuously after 4 or more hours of fasting.
No Improvement/Deterioration: Give patients with severe symptomatic presentations (coma, seizures, focal
neurologic signs) IV 5% dextrose (in normal or half-normal saline) after recovery. Observe 12-24 hours.
Recurrent hypoglycemia following treatment mandates additional 50% dextrose and evacuation. Consider
pituitary or adrenal insufficiency, renal or hepatic failure.

Follow-up Actions
Return evaluation: Routine diabetes-oriented care should suffice for most patients.
Evaluation/Consultation Criteria: Severe (coma, seizure, focal neurologic presentation) or frequent (> 1
severe episode per month) hypoglycemia should be evacuated.

Endocrine: Thyroid Disorders

Col Stephen Brietzke, USAF, MC

Introduction: Goiter is an enlargement of the thyroid gland, which can be appreciated visually or by
palpation. In part, goiter is an adaptive process, reecting increased size and number of thyroid follicles in
an attempt to overcome decient production of thyroid hormones by individual cells. Other causes of thyroid
enlargement include chronic inammation and scarring. Worldwide, a common cause of simple goiter is iodine
deciency. This condition is not expected in island or coastal regions where seafood or kelp (iodine-rich foods)
is consumed regularly, but may occur inland in large continents. Areas of the world where iodine deciency is
known to be a signicant problem include mountainous regions, parts of sub-Saharan Africa and central China.
Hyperthyroidism (overactive thyroid) is most commonly due to Graves’ disease, an autoimmune disease
caused by an antibody directed against the thyroid stimulating hormone (TSH) receptor (the “on/off” switch)
on the hormone producing cell. Another cause, multinodular goiter, results when thyroid cells lose the normal
“on/off” switch control of TSH and produce thyroid hormone independently. Finally, hyperthyroidism can result