Hypoglycemia: The Stroke Mimic You’ll Miss at 3AM

The Stroke Mimic You Will Miss at 3 AM

It is the 3 AM call for an “unresponsive person.” You find an elderly patient, diaphoretic, with a left-sided facial droop and weakness in their left arm. The family says they were fine when they went to bed. Every synapse in your brain is firing: STROKE. You activate a stroke alert, load the patient, and race to the hospital.

And you might be completely wrong.

Hypoglycemia is the great imitator. It can mimic a stroke, a seizure, a psychiatric emergency, or simple intoxication. Missing it is one of the easiest and most dangerous traps to fall into, especially when you are tired.

Recognition Patterns and Assessment Tricks

The brain runs on glucose. When it does not have enough, it malfunctions in bizarre ways. While the classic signs are altered mental status, diaphoresis, and tachycardia, you must be suspicious of focal neurological deficits. A patient can present with hemiparesis (one-sided weakness), aphasia (inability to speak), or seizures, all caused by low blood sugar starving a specific part of the brain.

This is why your first assessment “trick” is a mantra: Check a blood glucose on anyone who is not acting right.

• Altered? Check a sugar.
• New-onset seizure? Check a sugar.
• Suspected stroke? Check a sugar.
• Found down? Check a sugar.

It is the one vital sign that can provide a definitive diagnosis and a direct, immediate treatment path.

Treatment Pearls Beyond D50

Dextrose 50% is our classic go-to. It works, but it is thick, caustic to veins, and can cause nasty tissue damage if it extravasates.

• Consider D10: Dextrose 10% is becoming a preferred alternative. It is less damaging to veins and reduces the risk of rebound hypoglycemia. You will give a larger volume (e.g., 100-150mL of D10 instead of 50mL of D50), but it is a safer infusion.
• Oral Glucose for the Win: If your patient is awake enough to protect their airway and swallow, oral glucose is the best first-line treatment. It is absorbed quickly and is the most physiologically normal way to raise blood sugar.
• Glucagon for No IV Access: When you cannot get an IV and the patient cannot swallow, glucagon IM is your lifeline. It takes longer to work (10-15 minutes) as it stimulates the liver to release its own glucose stores, but it is incredibly effective.
• The Most Important Step: Food. After you have corrected the acute hypoglycemia, the patient must eat something with complex carbohydrates and protein—a sandwich, crackers with peanut butter. Dextrose is a short-term fix. Without real food, their sugar will crash again in an hour.

Documentation That Protects You

Your documentation is your best defense. When you suspect a stroke but find hypoglycemia, chart it clearly.

• Initial Findings: “Patient presents with right-sided weakness and slurred speech, consistent with CVA.”
• Intervention & Reassessment: “Initial BGL of 32 mg/dL. Administered 25g D50 IV. Upon reassessment, BGL is 115 mg/dL, and patient has complete resolution of all neurological deficits. Patient is now A&O x4.”

This narrative proves you identified a life-threatening condition, treated it appropriately, and resolved the “stroke” on scene.