Reasons for an overdose:
(1) accidental, including dose miscalculation
(2) intent to induce a factitious condition
(3) suicide attempt
(4) homicide
Steps:
(1) rapid reversal of hypoglycemia
(2) management of cerebral complications
(3) prolonged observation for long-acting preparations
(4) identifying and addressing the cause of the overdosage
Reversal of the hypoglycemia:
(1) Infuse 25-50% glucose solutions. Glucose solutions with a lower percentage may result in water intoxication due to the volumes required.
(2) Octreotide or diazoxide may be helpful in reversing the hypoglycemia if a sulfonylurea has been ingested.
(3) Glucose levels should be monitored to prevent overtreatment which can result in hyperglycemia.
Management of cerebral complications:
(1) If the patient has not regained consciousness after 10-15 minutes of starting glucose replacement then cerebral edema should be suspected.
(2) Management of cerebral edema includes intravenous dexamethasone and mannitol.
(3) Some physicians administer 100 mg of hydrocortisone IV immediately on starting glucose therapy.
If a long-acting insulin or sulfonylurea were administered, then the patient should be observed for 24 hours after the initial resuscitation. The patient is at risk for recurrence of the hypoglycemia if discharged too soon.
If the cause can be determined to be accidental then the patient can be discharged with education to prevent a recurrence. A person should not be discharged if the other 3 causes are suspected. A psychiatric evaluation should be performed if there is evidence for factitious hypoglycemia or a suicide attempt. The police should be consulted if a homicide was attempted.
