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Hypoglycemia Management
Aka: Hypoglycemia Management, Hypoglycemia Management in Diabetes Mellitus, Emergency Glucose Replacement, Insulin Shock, Insulin Overdose, Insulin Reaction
- See Also
- Hypoglycemia
- Diabetes Mellitus Glucose Management
- Diabetes Sick Day Management
- Preparations
- Oral: Equivalents of 15 grams Glucose (1 carbohydrate)
- Three Glucose tablets (or 15 grams of Glucose gel)
- Fruit juice 1/2 cup (4 ounces)
- Regular soda 3/4 cup (6 ounces)
- Milk 1 cup (8 ounces)
- Honey or corn syrup 3 teaspoons
- Crackers (6 saltine crackers)
- Glucagon Intramuscular or Subcutaneous
- Precautions
- Transient effects only
- Ineffective when Liver Glycogen depleted
- Vomiting and aspiration risk
- Roll patient onto their side when used
- Dose
- Teens and adult: 1 mg
- Children: 0.5 mg (0.5 ml) or 15 mcg/kg
- 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)
- https://www.aliem.com/2014/12/d50-vs-d10-severe-hypoglycemia-emergency-department/
- 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
- Other measures
- Octreotide 100 mcg IM for one dose
- Suppresses endogenous Insulin release (but does not effect exogenous Insulin effects)
- Protocol: Immediate Oral Glucose Replacement
- Mild Hypoglycemia (BG 60-70 mg/dl): Give 15 carb grams
- Glucose oral gel 40% 15 grams orally or
- Glucose 3 tablets orally or
- Juice 4 ounces orally
- Moderate Hypoglycemia (BG 45-59): Give 20 carb grams
- Glucose oral gel 40% 20 grams orally or
- Glucose 4 tablets orally or
- Juice 6 ounces orally or
- Dextrose D10W 100 ml IV or D50 25 ml IV
- Severe Hypoglycemia (BG <45): Give 30 carb grams
- Glucose oral gel 40% 30 grams orally or
- Glucose 6 tablets orally or
- Juice 8 ounces orally or
- Dextrose D10W 100 ml IV or D50 25 ml IV
- 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
- 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)
- Deliver Glucagon to temporize briefly until Glucose can be absorbed
- Deliver Emergency Glucose Replacement (15-20 grams carbohydrate)
- 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
- 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)
- 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
- Oral Hypoglycemic agents
- Metformin (Glucophage)
- Unlikely to cause Hypoglycemia
- Sulfonylureas
- Prolonged Insulin release stimulation - observe for 24 hours
- Consider Octreotide 50-100 mcg IV
- 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
- Indications for hospital observation stay
- Hypoglycemia on Sulfonylurea
- Elderly patients (esp. with Dementia, Renal Insufficiency)
- Prevention
- See Hypoglycemia
- See Diabetes Mellitus Glucose Management
- See Diabetes Sick Day Management
- 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