December 2001

By James R. Roberts, MD

A prisoner in a correctional facility was brought to the emergency department (ED) after he was observed in his cell to be agitated and unresponsive. The night before, he had been involved in a minor fight with other prisoners at the jail but did not appear to have been injured. He seemed normal at the midnight cell check and had no known medical problems. In the ED, the man was diaphoretic, combative, and nonverbal and had to be restrained. His vital signs were normal except for a temperature of 95°F and a sinus rhythm of 110/minute. Physical examination revealed a bruise behind the left ear (see photo above), but the ear canal and tympanic membrane were normal. A computed tomographic (CT) scan was ordered, but the man had a seizure before the procedure could be performed, and he was brought back to the ED to undergo sedation before another attempt could be made. Considering a diagnosis of head trauma, the clinicians on duty decided to paralyze and intubate the patient so that the CT scan could be performed.

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The patient appeared to have a classic Battle's sign, indicative of a basilar skull fracture. Given this finding and the history of a recent fight, the clinicians were certainly correct to focus on a diagnosis of significant head trauma. However, classic signs of hypoglycemia—hypothermia, diaphoresis, significant agitation, and subsequent seizure—were present and should have been noted. During intubation, the physicians were notified of the results of the patient's blood tests, which indicated a critical glucose level of 2 mg/dl. Intravenous dextrose quickly calmed the patient, and his condition gradually stabilized.

A further delay in diagnosis might have been catastrophic, however. A subsequent CT scan yielded negative results, and the bruising behind the ear was attributed to direct soft tissue trauma sustained in the previous night's brawl. On further investigation, it was discovered that the patient had been in a fight over drugs that had been smuggled into the facility. Although he thought he was scoring methadone, the drug he actually took was the oral hypoglycemic agent glipizide. Any patient—whether a newborn or a nursing home resident—who presents with an altered mental status must undergo an expeditious evaluation for hypoglycemia. That step should be as routine as taking a blood pressure reading. Even the first-year medical student knows that the need to check glucose levels is axiomatic if the patient has a history of diabetes, but unexpected hypoglycemia has fooled every busy, seasoned clinician at some time. Clandestine hypoglycemia is most frequently overlooked when a physician is certain about an alternate diagnosis. Among the conditions that mimic hypoglycemia and are well known to embarrass even the most experienced clinician are classic cases of drug overdose and alcohol intoxication. Similarly, unconscious patients who have suffered multiple trauma must also undergo an immediate evaluation for hypoglycemia, as should psychiatric patients who present with decompensation or those thought to be suffering from stroke or sepsis.

Emerg Med 33(12):57, 2001

Dr. Roberts is professor of emergency medicine at the Medical College of Pennsylvania and chairman of the department of emergency medicine at Mercy Catholic Medical Center in Philadelphia. He is also a member of the Emergency Medicine editorial board.