a) correct application of glucose monitoring; b) treatment of symptomatic hypoglycemia.
Patient description
Inclusion criteria
Adult or juvenile patients with a glucose score below 3.5 mmol/L (60 mg/dL) and symptoms of hypoglycemia.
Adult or juvenile patients with altered level of consciousness (see instruction “Violation of the mental state”).
Adult or juvenile patients with stroke symptoms (e.g. – hemiparesis, dysarthria) (see instruction “Suspected stroke/Transient ischemic attack”).
Adult or juvenile patients with seizures (see instruction “Convulsions”).
Adult or minor patients with a history of diabetes and symptoms of other diseases.
Children with suspected alcohol use.
Adult patients with signs of intoxication.
Exclusion criteria
Patients with cardiac arrest.
Patient care
Condition assessment
1. Monitoring. Check glucose levels.
2. Secondary examination for altered glucose levels:
a) evaluate the presence of automatic external insulin delivery devices (insulin pump); b) cardiovascular system – assess the presence of tachycardia and hypotension; c) eyes – evaluate the presence of “sunken” eyes due to dehydration; d) nose/mouth/ears – assess the presence of drying of the mucous membrane or bite of the tongue due to seizures; е) neurological examination:
assess the state of consciousness by GCS;
assess the presence of focal neurological deficiency – motor and sensory.
Treatment and intervention
1. With an altered level of consciousness or stroke, treatment according to the instruction “Disturbance of mental state” or “Suspicion of stroke/Transient ischemic attack,” respectively.
2. If glucose is 3.3 mmol/L (60 mg/dL) and below, inject one of these drugs.
2.1. Conscious patient with airway:
a) glucose, orally (in the form of glucose tablets, glucose gel, tubes with ice crust, etc.):
adults: dose – 25 g; children: dose – 0.5-1 g/kg.
2.2. Unconscious patient or, who alone is not able to control the respiratory tract:
a) IV dextrose – inject with a gradual increase in the dose until the state of consciousness improves or the maximum cumulative dose is achieved.
Maximum dose for adults:
25 g 10-50% iv dextrose
50 ml 50% dextrose
100 ml 25% dextrose
250 ml 10% dextrose
Maximum dose for children:
0.5-1 g/kg 10-25% iv dextrose
2-4 ml/kg 25% dextrose
4-8 ml/kg 12.5% dextrose
5-10 ml/kg 10% dextrose;
b) glucagon IV/m/nasally
Adults: 1 mg w/w/nasal
Children:
1 mg w/w/nasal if the weight ≥ 20 kg or ≥ 5 years
0.5 mg w/w/nasal if the weight is less than 20 kg or younger than 5 years;
c) remove or disconnect the insulin pump if it interferes with the completion of the above procedures.
2.3. For patients with insulin pump who have hypoglycemia with associated altered state of consciousness (GFR < 15 points):
a) stop the pump or disconnect if the patient cannot swallow oral glucose on his own or if specialized care is not available; b) leave the pump in the working position if the patient is able to swallow independently and receives specialized assistance.
3. Re-evaluate the patient:
a) re-evaluate vital signs and state of consciousness; b) re-check the glucose level if there are no changes in consciousness and manifestation of hypoglycemia; there is no need to re-determine glucose if consciousness has returned to normal; c) if the maximum dose of glucose did not lead to euglycemia and normalization of consciousness:
transport to the nearest admission department for further treatment of persistent hypoglycemia;
assess the existence of alternative causes of changes in consciousness;
continue treatment with dextrose solutions as above;
4. Hospitalization:
a) if symptoms of hypoglycemia continue, transport to the nearest admission department; b) patients with hypoglycemia who have had seizures should be taken to the admission department regardless of the state of consciousness and response to therapy; c) if the symptoms of hypoglycemia have passed after treatment, then the patient can be left without hospitalization if:
repeated determination of glucose greater than 4.4 mmol/L (80 mg/dL);
patient insulin or metformin for diabetes control;
restoring consciousness without focal neurological symptoms/signs after glucose/dextrose administration;
the patient can independently eat food enriched with carbohydrates;
the patient or guardian refuses transportation and EMF employees agree with this;
someone responsible will be next to the patient;
absence of serious concomitant symptoms, such as, for example: chest pain, shortness of breath, convulsions, intoxication;
an unequivocal cause of hypoglycemia was identified (for example, irregular food intake).
Patient safety
10% dextrose can be safely used in patients of all age groups.
50% of dextrose can cause local tissue damage if it enters the tissues through a damaged vein and can cause hyperglycemia. Also, 50% dextrose sometimes causes a slight improvement.
EMD systems may consider the use of no more than 25% dextrose concentration for the treatment of hypoglycemia in adults.
For children under 8 years of age, it is necessary to apply a dextrose concentration of no more than 25%.
For infants and children younger than 1 month, the maximum dextrose concentration for use is 10-12.5%.
Sulfonylurea (for example, glyburide, glipizide, etc.) have a long half-life of 12-60 hours. Patients with treated hypoglycemia and who use these drugs have a high risk of recurrence of symptoms, so often require hospitalization.
Useful information for training
Calculation formula 0.5 g/kg dose for iv administration of dextrose:
Remember the possibility of using diabetic drugs in tablet form for hypoglycemia.
If possible, ask family members to disconnect the insulin pump (dispenser).
Remember the possibility of a conscious overdose of hypoglycemic agents.
Do not convert hypoglycemia to hyperglycemia. Slowly inject fluids containing IV dextrose until the state of consciousness improves or the maximum dose is reached.
Relevant evaluation results
Concomitant injury.
Sweating or hypothermia may be associated with hypoglycemia.
Key elements of documentation
Documentation of the facts of repeated verification of vital signs and state of consciousness after the introduction of IV fluids.
Documentation of glucose level (if practice level allows) if necessary.
Criteria for the effectiveness of care
Determination of blood glucose should be made for each patient with changes in the level of consciousness, convulsions, stroke or hyperglycemia.
If the patient is not hospitalized, document the causes.
