Glucose Emergencies 

Assessment

Pediatric Pearls: Signs & Symptoms: Differential: 
□ Use approved reference document for medication dosing, electrical therapy, and equipment sizes. 

□ Newborn hypoglycemia is below 40 mg/dL 

□ Can only use D10 for infants (not D50)

□ If there is a concern for DKA, consider 20cc/kg fluid bolus		□ Altered Mental Status 
□ Seizure 
□ Reported low blood sugar prior to arrival 
□ Shakiness 
□ Stroke-like deficits 
□ Sweating 
□ Lethargy 
□ Difficulty Breathing 
□ Kussmaul respirations		□ Infections / Sepsis 
□ Medication under/overdose 
□ Liver failure 
□ Stroke 
□ Seizure 
□ Cancer 
□ Electrolyte abnormalities 
□ Alcoholism 

Clinical Management Options

EMT-B
• Oxygen, target SpO2 92 – 96% 
• BGL Assessment, if BGL < 60 and intact gag reflex then Oral Glucose  
• Consider removing the insulin pump if present. Please bring the insulin pump if present
• Basic Airway Management as needed 
Paramedic
• Vascular access 
• If BGL < 60 then Dextrose Infusion titrated to patient condition and response 
• Consider IM glucagon if the patient is agitated and hypoglycemic
• If no IV access IO/Dextrose 
• If BGL > 300 (adults)/> 200 (pediatrics) or signs of dehydration, give an IV fluid bolus  
• ECG Monitoring 
• Monitor for hyperkalemia changes and treat with Calcium, Albuterol, and Sodium Bicarbonate if present 
• Monitor EtCO2 if BGL > 550 mg/dl 
• If EtCO2 < 21 mmHg, Advise ED of Diabetic Ketoacidosis 
• If using mechanical ventilation, ensure high minute volume 
Consult Online Medical Control as Needed

Pearls

  • Hyperglycemia
    • New onset diabetic ketoacidosis in pediatric patients commonly presents with nausea, vomiting, abdominal pain, and/or urinary frequency  
    • Consider causes for hyperglycemia by thinking about the 3 I’s:
      • Insulin – this refers to any medication changes for insulin or oral medications including poor compliance or malfunctioning insulin pump  
      • Ischemia – this refers to hyperglycemia sometimes being an indication of physiologic stress in a patient and can be a clue to myocardial ischemia in particular  
      • Infection – underlying infection can cause derangements in glucose control  
  • Hypoglycemia
    • Glucagon works by releasing glucose stores. It will not work in patients who have chronic hypoglycemia (starvation, chronic alcohol use, cancers, etc).
    • D10 has a faster onset compared to glucagon and should be used in critically ill patients.
    • Consider contribution of oral diabetic medications to hypoglycemia  
    • If possible, have family/patient turn off insulin pumps  
    • Consider potential for intentional overdose of hypoglycemic agents  
    • Avoid overshoot hyperglycemia when correcting hypoglycemia. Administer dextrose – containing IV fluids in small doses until either mental status improves or a maximum field dose is achieved.
Hypoglycemia Treatment-In-Place Checklist
□ Has a known history of diabetes
□ Repeat glucose is greater than 80mg/dL
□ Patient takes glucose for insulin control (no oral hypogylcemics)
□ There is a clear and reversible cause for the hypoglycemia (ie. Missed a meal)
□ There was no medication error (too much long-acting insulin must be transported)
□ Patient’s mental status has returned to baseline 
□ Patient is able to obtain and eat a carbohydrate meal (needs to be immediately available, take at least a few bites)
□ Someone can stay with the patient for the next several hours and monitor the patient
□ Patient is willing and would prefer to stay at home for home treatment