Hypoglycemia

Table of Contents

Aliases

Diabetic coma, insulin shock

Patient Care Goals

  1. Limit morbidity from hypoglycemia by:
    1. Describing appropriate use of glucose monitoring
    2. Treating symptomatic hypoglycemia

Patient Presentation

Inclusion Criteria

  1. Adult or pediatric patient with blood glucose less than or equal to 60 mg/dL with symptoms of hypoglycemia
  2. Adult or pediatric patient with altered level of consciousness [see Altered Mental Status guideline]
  3. Adult or pediatric patient with stroke symptoms (e.g. hemiparesis, dysarthria) [see Suspected Stroke/Transient Ischemic Attack guideline]
  4. Adult or pediatric patient with seizure [see Seizures guideline]
  5. Adult or pediatric patient with history of diabetes and other medical symptoms
  6. Pediatric patient with suspected alcohol ingestion
  7. Adult patient who appears to be intoxicated

Exclusion Criteria

Patient in cardiac arrest

Patient Management

Assessment

  1. Monitoring:
    1. Check blood glucose level
  2. Secondary survey pertinent to altered blood glucose level:
    1. Evaluate for presence of an automated external insulin delivery device (insulin pump)
    2. Constitutional: assess for tachycardia and hypotension
    3. Eyes: assess for sunken eyes from dehydration
    4. Nose /mouth/ears: assess for dry mucus membranes or tongue bite from seizure
    5. Neurologic:
      1. Assess GCS and mental status
      2. Assess for focal neurologic deficit: motor and sensory

Treatment and Interventions

  1. If altered level of consciousness or stroke, treat per Altered Mental Status or Suspected Stroke/Transient Ischemic Attack guidelines accordingly
  2. If blood glucose is 60 mg/dL or less, administer one of the following:
    1. Conscious patient with a patent airway:
      1. Glucose, oral (in form of glucose tablets, glucose gel, tube of cake icing, etc.)
        1. Adult Dosing: 15 g
        2. Pediatric Dosing: 1 g/kg, max of 15 g
    2. Unconscious patient, or patients who are unable to protect their own airway:
      1. Dextrose IV – administer in incremental doses until mental status improves
        1. Adult Dosing:
          1. 250 ml of 10% dextrose IVPB Wide Open or IVP
        2. Pediatric Dosing:
          1. 5 ml/kg of 10% dextrose IVP
      2. Glucagon IM/IN
        1. Adult dosing: 1 mg IM/IN
        2. Pediatric dosing:
          1. 1 mg IM/IN if 20 kg (or  5 yo)
          2. 0.5 mg IM/IN if less than 20 kg (or less than 5 yo)
      3. Remove or disable insulin pump if above treatments cannot be completed
    3. For patients with an insulin pump who are hypoglycemic with associated altered mental status (GCS <15):
      1. Stop the pump, disconnect or remove at insertion site if patient cannot ingest oral glucose or ALS is not available
      2. Leave the pump connected and running if able to ingest oral glucose or receive ALS interventions
  3. Reassess patient
    1. Reassess vital signs, blood glucose level, and mental status
    2. If dextrose/glucagon does not achieve euglycemia (glucose 60 mg/dL) and normalization of mental status:
      1. Continue treatment of hypoglycemia as noted above
        1. It is acceptable to switch to oral glucose after giving IV dextrose
      2. Initiate transport to closest appropriate receiving facility for further treatment of refractory hypoglycemia
      3. Evaluate for alternative causes of altered mental status
  4.  Disposition
    1. If hypoglycemia with continued symptoms, transport to closest appropriate receiving facility
    2. Hypoglycemic patients who have had a seizure should be transported to the hospital regardless of their mental status and response to therapy
    3. If symptoms of hypoglycemia resolve after treatment, release without transport should only be considered if all of the following are true:
      1. Repeat glucose is greater than 80 mg/dL
      2. Patient takes insulin and/or metformin ONLY to control diabetes
      3. Patient returns to normal mental status, with no focal neurologic signs/symptoms after receiving glucose/dextrose
      4. Patient can promptly obtain and will eat a carbohydrate meal
      5. Patient or legal guardian refuses transport and EMS providers agree transport not indicated
      6. A reliable adult will be staying with patient
      7. No major co-morbid symptoms exist, like chest pain, shortness of breath, seizures, intoxication
      8. A clear cause of the hypoglycemia is identified (e.g. missed meal)

Notes – Hypoglycemia