Hypoglycemia Management

Aka: Hypoglycemia Management, Hypoglycemia Management in Diabetes Mellitus, Emergency Glucose Replacement, Insulin Shock, Insulin Overdose, Insulin Reaction

1. See Also
   1. Hypoglycemia
   2. Diabetes Mellitus Glucose Management
   3. Diabetes Sick Day Management
2. Findings
   1. See Hypoglycemia
3. Labs
   1. Glucose monitoring
      1. Obtain at least hourly Glucose values while observing
   2. Medication Overdose
      1. See Sulfonylurea Overdose
      2. See Unknown Ingestion
      3. Insulin Overdose
         1. Obtain serum Electrolytes (risk of Hypoglycemia and Hypokalemia)
      4. Plasma Insulin Level and C-Peptide Levels
         1. Factitious Hypoglycemia is the intentional, surreptitious use of hypoglycemic agent to induce Hypoglycemia
         2. Following Insulin use, plasma Insulin will be high and C-peptide will be low (<0.02)
         3. Following Sulfonylurea, plasma Insulin will be high and C-peptide will be high
4. Preparations
   1. Oral: Equivalents of 15 grams Glucose (1 carbohydrate)
      1. Three Glucose tablets (or 15 grams of Glucose gel)
      2. Fruit juice 1/2 cup (4 ounces)
      3. Regular soda 3/4 cup (6 ounces)
      4. Milk 1 cup (8 ounces)
      5. Honey or corn syrup 3 teaspoons
      6. Crackers (6 saltine crackers)
   2. Glucagon Intramuscular or Subcutaneous
      1. Precautions
         1. Transient effects only
         2. Ineffective when Liver Glycogen depleted
         3. Vomiting and aspiration risk
            1. Roll patient onto their side when used
      2. Dose
         1. Teens and adult: 1 mg
         2. Children: 0.5 mg (0.5 ml) or 15 mcg/kg
   3. Administer Intravenous Dextrose
      1. Bolus
         1. One ampule (25 g) of D50W is 100 KCal and raises Blood Glucose 100 mg/dl
         2. Adult: 0.5 to 1 g/kg or 10-25 ml of D50W (25 g in 50 mL) IV
         3. Infant: 0.5 to 1 g/kg of D25W (2.5 g Glucose per 10 ml prefilled syringe)
         4. Alternative: 100 ml of D10W IV
            1. Less likely to cause rebound Hypoglycemia than D50W
            2. D50 vs D10 for Severe Hypoglycemia in the Emergency Department (Aliem)
               1. https://www.aliem.com/2014/12/d50-vs-d10-severe-hypoglycemia-emergency-department/
      2. Maintenance: D10W IV at 100 cc/hour (10 g/h or 40 cal/h) until stable
         1. If persistent higher concentrations are needed (e.g. D50W), then obtain central venous access
      3. Keep plasma Glucose over 100 mg/dl
   4. Other measures
      1. Octreotide 100 mcg IM for one dose
         1. Suppresses endogenous Insulin release (but does not effect exogenous Insulin effects)
5. Protocol: Immediate Oral Glucose Replacement
   1. Mild Hypoglycemia (BG 60-70 mg/dl): Give 15 carb grams
      1. Glucose oral gel 40% 15 grams orally or
      2. Glucose 3 tablets orally or
      3. Juice 4 ounces orally
   2. Moderate Hypoglycemia (BG 45-59): Give 20 carb grams
      1. Glucose oral gel 40% 20 grams orally or
      2. Glucose 4 tablets orally or
      3. Juice 6 ounces orally or
      4. Dextrose D10W 100 ml IV or D50 25 ml IV
   3. Severe Hypoglycemia (BG <45): Give 30 carb grams
      1. Glucose oral gel 40% 30 grams orally or
      2. Glucose 6 tablets orally or
      3. Juice 8 ounces orally or
      4. Dextrose D10W 100 ml IV or D50 25 ml IV
   4. Unconscious with severe Hypoglycemia (BG<45)
      1. Dextrose 50% 25 ml IV or
      2. Glucagon 1 mg SQ or IM (0.5 mg for child)
         1. Vomiting and aspiration risk
         2. Roll patient onto their side when used
6. Protocol: Approach
   1. Recognize signs of Hypoglycemia (e.g. Altered Level of Consciousness or confusion, sweating, Dizziness)
      1. Test Blood Glucose for Hypoglycemia symptoms (but do not delay replacement)
   2. Treat Hypoglycemia if Blood Glucose <70 mg/dl (or <80-90mg/dl in elderly)
      1. Deliver Glucagon to temporize briefly until Glucose can be absorbed
      2. Deliver Emergency Glucose Replacement (15-20 grams carbohydrate)
   3. Glucose monitoring
      1. Monitor Blood Glucose every 15 minutes until >100 mg/dl
      2. Redose Glucose replacement per above every 15 min as needed
   4. Eat a small meal (e.g. turkey sandwich) that contains protein and fat once Blood Glucose has returned to a normal level
7. Precautions
   1. Acute Hypoglycemia associated with long acting Oral Hypoglycemic agents (e.g Sulfonylureas)
      1. See Sulfonylurea Overdose
      2. Observe in hospital setting until hypoglycemic agent has been sufficiently cleared to prevent further Hypoglycemia
   2. Consider differential diagnosis
      1. See Hypoglycemia causes
      2. Septic Shock (esp. in the elderly)
      3. Impaired liver function
      4. Alcohol may predispose to Hypoglycemia
   3. Insulin Overdose may have prolonged and recurrent Hypoglycemia
      1. Ultralente related Hypoglycemia may recurr over days
      2. Decreased Renal Function prolongs Insulin half life
      3. In some cases of basal Insulin, Hypoglycemia may be delayed >12-18 hours
8. Management: Emergency Department Disposition
   1. Glucose correction
      1. D50W administration
         1. D50W results in rebound Hypoglycemia (consider 100 ml D10W instead, see above)
         2. After correction, observe for several hours with Glucose checked every 1-2 hours
      2. Meal after correction
         1. Patient must have some longer acting foods to prevent recurrent Hypoglycemia
         2. Give complex carbohydrates, protein and fat
         3. Consider Nasogastric Tube placement to deliver enteral carbohydrates if unable to take orally
   2. Oral Hypoglycemic agents
      1. Metformin (Glucophage)
         1. Unlikely to cause Hypoglycemia
      2. Sulfonylureas
         1. Prolonged Insulin release stimulation - observe for 24 hours
         2. Consider Octreotide 50-100 mcg IV
   3. Short-Acting Insulin (e.g. Humalog/Lispro, Novolog/Aspart)
      1. Short duration of observation after correction (peaks in 1 hour)
      2. However, large Insulin Overdoses may have a depot effect that lasts >24 hours
   4. Long-acting Insulin (basal Insulin)
      1. Lantus (Insulin Glargine)
         1. Constant basal rate without peak is unlikely to cause Hypoglycemia
         2. Typically does not affect disposition timing
      2. Levemir (Detemir)
         1. Onset at 1-2 hours and peak activity at 6-8 hours
         2. Observe for 6-8 hours with recheck Glucose every 1-2 hours
      3. Insulin Pump
         1. Detach and check pump for malfunction
   5. Indications for hospital observation stay
      1. Hypoglycemia on Sulfonylurea
      2. Elderly patients (esp. with Dementia, Renal Insufficiency)
9. Prevention
   1. See Hypoglycemia
   2. See Diabetes Mellitus Glucose Management
   3. See Diabetes Sick Day Management
10. References
    1. Herbert, Cardy, Swadron in Herbert (2018) EM:Rap 18(4): 13-4
    2. Orman and Willis in Herbert (2017) EM:Rap 17(6):6-7
    3. Tomaszewski (2021) Crit Dec Emerg Med 35(4): 28