II. Preparations
- Oral: Equivalents of 15 grams Glucose (1 carbohydrate)
- Glucagon Intramuscular or Subcutaneous
- Administer Intravenous Dextrose
- Bolus: 10-25 ml of D50W (25 g in 50 mL) IV
- One ampule (25 g) of D50W is 100 KCal and raises Blood Glucose 100 mg/dl
- Alternative: 100 ml of D10W IV
- Less likely to cause rebound Hypoglycemia than D50W
- D50 vs D10 for Severe Hypoglycemia in the Emergency Department (Aliem)
- Maintenance: D10W IV at 100 cc/hour (10 g/h or 40 cal/h) until stable
- If persistent higher concentrations are needed (e.g. D50W), then obtain central venous access
- Keep plasma Glucose over 100 mg/dl
- Bolus: 10-25 ml of D50W (25 g in 50 mL) IV
- Other measures
III. Protocol: Immediate Oral Glucose Replacement
- Mild Hypoglycemia (BG 60-70 mg/dl): Give 15 carb grams
- Moderate Hypoglycemia (BG 45-59): Give 20 carb grams
- Severe Hypoglycemia (BG <45): Give 30 carb grams
- Unconscious with severe Hypoglycemia (BG<45)
- Dextrose 50% 25 ml IV or
- Glucagon 1 mg SQ or IM (0.5 mg for child)
- Vomiting and aspiration risk
- Roll patient onto their side when used
IV. Protocol: Approach
- Recognize signs of Hypoglycemia (e.g. Altered Level of Consciousness or confusion, sweating, Dizziness)
- Test Blood Glucose for Hypoglycemia symptoms (but do not delay replacement)
- Treat Hypoglycemia if Blood Glucose <70 mg/dl (or <80-90mg/dl in elderly)
-
Glucose monitoring
- Monitor Blood Glucose every 15 minutes until >100 mg/dl
- Redose Glucose replacement per above every 15 min as needed
- Eat a small meal (e.g. turkey sandwich) that contains protein and fat once Blood Glucose has returned to a normal level
V. Precautions
- Acute Hypoglycemia associated with long acting Oral Hypoglycemic agents (e.g Sulfonylureas)
- Observe in hospital setting until hypoglycemic agent has been sufficiently cleared to prevent further Hypoglycemia
- Consider differential diagnosis
- See Hypoglycemia causes
- Septic Shock (esp. in the elderly)
VI. Management: Emergency Department Disposition
-
Glucose correction
- D50W administration
- D50W results in rebound Hypoglycemia (consider 100 ml D10W instead, see above)
- After correction, observe for several hours with Glucose checked every 1-2 hours
- Meal after correction
- Patient must have some longer acting foods to prevent recurrent Hypoglycemia
- Give complex carbohydrates, protein and fat
- Consider Nasogastric Tube placement to deliver enteral carbohydrates if unable to take orally
- D50W administration
-
Oral Hypoglycemic agents
- Metformin (Glucophage)
- Unlikely to cause Hypoglycemia
- Sulfonylureas
- Prolonged Insulin release stimulation - observe for 24 hours
- Consider Octreotide 50-100 mcg IV
- Metformin (Glucophage)
-
Short-Acting Insulin (e.g. Humalog/Lispro, Novolog/Aspart)
- Short duration of observation after correction (peaks in 1 hour)
- However, large Insulin Overdoses may have a depot effect that lasts >24 hours
- Long-acting Insulin (basal Insulin)
- Lantus (Insulin Glargine)
- Constant basal rate without peak is unlikely to cause Hypoglycemia
- Typically does not affect disposition timing
- Levemir (Detemir)
- Onset at 1-2 hours and peak activity at 6-8 hours
- Observe for 6-8 hours with recheck Glucose every 1-2 hours
- Insulin Pump
- Detach and check pump for malfunction
- Lantus (Insulin Glargine)
- Indications for hospital observation stay
- Hypoglycemia on Sulfonylurea
- Elderly patients (esp. with Dementia, Renal Insufficiency)
VII. Prevention
VIII. References
- Herbert, Cardy, Swadron in Herbert (2018) EM:Rap 18(4): 13-4
- Orman and Willis in Herbert (2017) EM:Rap 17(6):6-7
Images: Related links to external sites (from Bing)
Related Studies
| Definition (NIC) | Preventing and treating low blood glucose levels |
| Concepts | Therapeutic or Preventive Procedure (T061) |
| SnomedCT | 386328006 |
| English | Hypoglycemia Management, hypoglycaemia management, hypoglycemia management, Hypoglycaemia management, Hypoglycemia management (procedure), Hypoglycemia management |
| Spanish | manejo de la hipoglucemia (procedimiento), manejo de la hipoglucemia |
Ontology: Insulin overdose (C0573713)
| Concepts | Injury or Poisoning (T037) |
| SnomedCT | 296849000 |
| English | insulin overdose, Insulin overdose, Insulin overdose (disorder) |
| Spanish | sobredosis de insulina (trastorno), sobredosis de insulina |
Ontology: Insulin Shock (C1527401)
| Definition (NCI_FDA) | A hypoglycemic reaction to overdosage of insulin, a skipped meal, or strenuous exercise in an insulin-dependent diabetic. |
| Definition (NCI) | A hypoglycemic reaction to overdosage of insulin, a skipped meal, or strenuous exercise in an insulin-dependent diabetic. |
| Definition (MSH) | Sudden significant drop in BLOOD GLUCOSE or hypoglycemic shock which affects the hemodynamic equilibrium of all vital organs. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D007331 |
| SnomedCT | 111558006 |
| English | Insulin Reaction, Shock insulin, INSULIN SHOCK, SHOCK, INSULIN, Shock, Insulin, Insulin shock, Insulin Shock |
| Dutch | insuline shock |
| German | Insulinschock, INSULINSCHOCK |
| Italian | Shock insulinico, Shock da insulina |
| Portuguese | Choque insulínico, CHOQUE INSULINICO |
| Spanish | Shock insulínico, SHOCK INSULINICO, choque insulínico, shock insulínico |
| Japanese | インスリンショック, ｲﾝｽﾘﾝｼｮｯｸ |
| French | Coma hypoglycémique, CHOC INSULINIQUE, Choc insulinique |
| Czech | Inzulinový šok, inzulinový šok |
| Hungarian | Insulin-shock, Insulin sokk |
| Norwegian | Insulinsjokk |
