Notes – Hypoglycemia

Hypoglycemia

Patient Safety Considerations

  1. Dextrose 10% can be safely used in all ages of patient
  2. Dextrose 50% can cause local tissue damage if it extravasates from vein, and may cause hyperglycemia. Dextrose 50% carries risk for little clinical gain. EMS systems may consider carrying no more than 25% concentration of dextrose for treating hypoglycemia in adults
  3. For children 8 yo, dextrose concentration of no more than 25% should be used
  4. For neonates and infants 1 month of age, dextrose concentration of no more than 10-12.5% should be used
  5. Sulfonylureas (e.g. glyburide, glipizide) have long half-lives ranging from 12-60 hours. Patients with corrected hypoglycemia who are taking these agents are at particular risk for recurrent symptoms and frequently require hospital admission

Notes/Educational Pearls

Key Considerations

  1. Consider contribution of oral diabetic medications to hypoglycemia
  2. If possible, have family/patient turn off insulin pumps
  3. Consider potential for intentional overdose of hypoglycemic agents
  4. 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

Pertinent Assessment Findings

  1. Concomitant trauma
  2. Diaphoresis or hypothermia may be associated with hypoglycemia

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914125 – Medical-Hypoglycemia/Diabetic Emergency

Key Documentation Elements

  • Document reassessment of vital signs and mental status after administration of glucose/dextrose/glucagon
  • Document point of care glucose level (if in scope of practice) when indicated

Performance Measures

  • When in scope of practice, blood glucose is checked for all patients with symptoms of altered level of consciousness, seizure, stroke, or hypoglycemia
  • If patient released at scene, criteria documented for safe release
  • EMS Compass® Measures (for additional information, see http://www.emscompass.org)
    • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms
    • Hypoglycemia-01: Treatment administered for hypoglycemia. Measure of patients who received treatment to correct their hypoglycemia

References

  1. A review of the efficiency of 10% dextrose as an alternative to high concentration glucose in the treatment of out-of-hospital hypoglycemia. J Emerg Prim Health Care. 2009;7(3):990341.
  2. Desachy A, Vuagnat AC, Ghazali AD, et al. Accuracy of bedside glucometry in critically ill patients: influence of clinical characteristics and perfusion index. Mayo Clin Proc. 2008;83(4):400-5.
  3. Funk DL, Chan L, Lutz N, Verdile VP. Comparison of capillary and venous glucose measurements in healthy volunteers. Prehosp Emerg Care. 2001;5(3):275-7.
  4. Hern HG, Kiefer M, Louie D, Barger J, Alter HJ. D10 in the treatment of prehospital hypoglycemia: a 24 month observational cohort study. Prehosp Emerg Care. 2017;21(1):63-7.
  5. Holstein A, Kuhne D, Elsing HG, et al. Practicality and accuracy of prehospital rapid venous blood glucose determination. Am J Emerg Med. 2000;18(6):690-4.
  6. Holstein A, Plaschke A, Vogel MY, Egberts EH. Prehospital management of diabetic emergencies – a population-based intervention study. Acta Anaesthesiol Scand. 2003;47(5):610-5.
  7. Jones JL, Ray VG, Gough JE, Garrison HG, Whitley TW. Determination of prehospital blood glucose: a prospective, controlled study. J Emerg Med. 1992;10(6):679-82.
  8. Kulkarni A, Saxena M, Price G, O’Leary MJ, Jacques T, Myburgh JA. Analysis of blood glucose measurements using capillary and arterial blood samples in intensive care patients. Intensive Care Med. 2005;31(1):142-5.
  9. Kumar G, Sng BL, Kumar S. Correlation of capillary and venous glucometry with laboratory determination. Prehosp Emerg Care. 2004;8(4):378-83.
  10. Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? a randomized controlled trial. Emerg Med J. 2005;22:512–5.
  11. Roberts K, Smith A. Outcome of diabetic patients treated in the prehospital arena after a hypoglycemic episode, and an exploration of treat and release protocols: a review of the literature. Emerg J Med. 2003;20(3):274-6.
  12. Vilke GM, Castillo EM, Ray LU, Murrin PA, Chan TC. Evaluation of pediatric glucose monitoring and hypoglycemic therapy in the field. Pediatr Emerg Care. 2005;21(1):1-5.