Hypoglycemia - Maryland Format

Applies to: PatientsBlood glucose less than 70 mg/dL or greater than 300 mg/dL

• Patient-reported low or high blood glucose
• Diabetic patients with bloodother sugarmedical <symptoms 60(e.g., mg/dl

  Exclusion Criteria: None

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  Recognize

  vomiting)
  • Altered mental status
  • AnxietyAlcohol intoxication, suspected
  • Slurred speechSeizure
  • SweatingStroke symptoms
  • PaleUnresponsive skinpatients
  • Tremors
  Cardiac
  • Seizures
  • Medic alert bracelet / jewelryarrest

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  EvaluateBLS

  • Primary survey with airway management
  • ObtainCheck blood glucose measurementlevel
  • If blood glucose is less than 70 mg/dL, administer 10-15 grams of oral glucose between the patient’s gum and cheek.
  • Administer additional dose of 10-15 grams of oral glucose if not improved after 10 minutes.

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  Administer TreatmentALS

  • HYPOglycemia: If blood glucose is less than 70 mg/dL, administer 10% dextrose in 50 mL (5 gram) boluses, 1 minute apart, to a maximum of 250 mL OR 25 grams of 50% dextrose IVP, until:
    • the patient has altereda return to normal mental statusstatus, with concerns of inability to protect airway, obtain IV access,
      reference Vascular Access (P33)and
    • Supplementalthe oxygen PRN for goal SpO2
    • Adult: treat patients with apatient’s blood glucose readingis ofat <least 7090 mg/dldL
    • • If patient is conscious, cooperative and can protect their airway, administer Oral Glucose 1-2
        tubes (15-30g) PO
      • If patient has persistently altered mental status orand thereblood glucose less than 90 mg/dL despite treatment, repeat dosing regimen above.
      • If unable to initiate an IV and blood glucose is concernless ofthan inability70 tomg/dL, protect airway,
        administer D10W,glucagon 1251 mLmg (12.5 gm) IV/IO over 10 minutes, may repeat PRN
        • IM/IN.
          • If D10Wthe ispatient has persistently altered mental status and blood glucose less than 90
            mg/dL at 15 minutes, transport to the hospital should not available,be administer Dextrose 50%, 25-50mL (12.5-25 gm) IV/IO over
            5 to 10 minutes, may repeat PRN
          delayed.
      • ConsiderHYPERglycemia: Glucagon 1mg IM (>20 Kg patients) if venous access unobtainable
  • RepeatIf blood glucose measurementis everygreater 30than minutes300 andmg/dL, treatadminister accordingly
  10
  • FormL/kg persistentLactated hypoglycemiaRinger’s despitebolus treatment,unless considerrales, awheezing, maintenancepedal infusionedema, withor escalating
    dextrosehistory concentrationof
    renal
    • failure
      or 
      • D12.5%CHF is the highest dextrose concentration that may be infused peripherally
      • Dextrose concentrations higher than D12.5% require a central line or IO
  • For refractory low blood glucose with coinciding hypotension, consider adrenal crisis and treat with
    Hydrocortisone (Solu-Cortef) 1mg/Kg IV/IO, max 100mg/dose, repeat PRN
    • • If Solu-Cortef is unavailable, treat with Methylprednisolone (Solu-Medrol) 2mg/Kg IV/IO,
        max 125mg/dose, repeat PRN
    present. 

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  Consider DifferentialsMC

  • EnvironmentalNot exposure
  • Toxic ingestion
  • Alcoholism
  • Sepsis
  • Metabolic etiology
  • Adrenal crisisApplicable

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  Transport Considerations

  • Blood glucose measurement is required on all patients less than 1 year of age, if not obtained at
    sending facility within the last 4 hours
  • Hypoglycemia and hypothermia often coexist. If one of these conditions exists, determine if the
    other is also present

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  Information

  • Hypoglycemia should be considered in any person with an altered LOC. However, glucose should not
    be administered unless the patient is actually hypoglycemic. Administration of glucose or dextrose to
    a patient who does not have hypoglycemia but instead has experienced a stroke resulting in an
    altered LOC could be detrimental
  • Remember that sick children have high metabolic requirements with high glucose utilization. Check
    blood glucose early and often
  • D10W is the preferred IV bolus solution to treat hypoglycemia
  • Abnormal glucose levels to be considered hypoglycemia and treated during transport:
    • • Adult < 70 mg/dl
      • Pediatric < 60 mg/dl
      • Neonatal < 50 mg/dl

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  Other Populations

  • Neonate and Pediatric Dosing: 
    • • Oral Glucose 0.2g/Kg PO (infant), 15g PO Pediatric
      • D10W, 2mL/Kg slow IV/UVC/IO over 10 minutes, may repeat PRN
      • Glucagon 0.5 mg IM (<20 Kg) or 1mg IM (>20 Kg) if venous access unobtainable
  • Neonate:
    • • Hypoglycemia has the potential for causing severe neurological damage
      • Symptoms manifest mostly from CNS (jittery, high pitch cry, seizures)
      • High glucose utilization may quickly deplete glycogen stores resulting in persistent hypoglycemia
      • Consider Inborn Error of Metabolism, specifically medium chain fatty acid deficiency (MCAD), in neonates with persistent hypoglycemia

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  References

  De Leon-Crutchlow, Diva D., et al. "Approach to Hypoglycemia in Infants and Children." UpToDate, Jul 2021.
  “U.S. Army Medevac Critical Care Flight Paramedic Standard Medical Operating Guidelines.” Jan 2020.
  Vella, A., et al. "Hypoglycemia in Adults without Diabetes Mellitus: Clinical Manifestations, Diagnosis, and
   Causes." UpToDate, Feb 2021.