A Hypoglycemic emergency is defined as blood glucose less than 3.0 mmol \ L or 60 mg/dL and associated signs with symptoms, such as altered mental status.

EMT Standing Order

• Routine Patient Care.
• Obtain glucose readings via glucometer.
• Oral glucose: administer 1 – 2 tubes of commercially prepared glucose gel, Patient must be alert enough to swallow and protect the airway.
• Call for Paramedic intercept, if available.
• For patients with an insulin pump who are hypoglycemic with associated altered mental status (GCS < 15):
• Stop the pump or remove the catheter at the insertion site if the patient cannot ingest oral glucose or the ALS team is not available.
• Leave the pump connected and running if able to ingest oral glucose or receive ALS interventions.
• Do not treat and release hypoglycemic patients without contacting Medical Direction to discuss the cause of hypoglycemic episodes, interventions taken and follow-up plan.
• Call for AEMT/Paramedic intercept. & Assisst AEMT/Paramedic in patient care.

AEMT/Paramedic Standing Order

• Establish IV access.
• Administer up to 25 grams of dextrose 50% IV. Recheck glucose 5 minutes after administration.
• May repeat up to 25 grams’ 50% IV if glucose level is < 60 mg/dl (3.3 mmol) with continued altered mental status.
• If unable to establish IV access, administer glucagon 1 mg IM. Recheck glucose 15 minutes after administration of glucagon.
• May repeat glucagon 1 mg IM if glucose level is < 60 mg/dl (3.3 mmol) with continued altered mental status.
• AEMT/Paramedic: If patient is seizing manage as per seizer protocol.

Caution:

• AEMT/Paramedic: If the patient has a severe hypoglycemic emergency with altered mental status or seizures and the provider is unable to establish IV access, the provider may administer dextrose via intraosseous (IO)
• If the patient is alert and oriented to person, place, time and events and able to protect their airway, administer 1 tube of GLUCOSE 15g po.
• If the blood sugar level is below 3.0 mmol/l or the patient has an altered level of consciousness.
  • Administer 50% DEXTROSE (25mg) slow IV push.
  • If IV/IO access cannot be obtained, then administer, GLUCAGON 1mg IM. This may be repeated once in 5 minutes if necessary.
  • If the hypoglycemic patient start to seize, maintain his airway and administer appropriate sedating agents (refer to seizure protocol).
  • Start 10% dextrose infusion on the way to health care facility.
  • Contact medical control for further orders.
  • Transport to designated health care.

MEDICAL CONTROL

• If little or no response after 5 minutes of administering the first 50% DEXTROSE administers a second dose of 50% DEXTROSE (25mg) IV push.
• In case of seizure or combative cases further doses of diazepam can be permitted.

PEARLS:

• There are no statistically significant differences in the median recovery time to a GCS score of 15 following administration of D10% versus D50%. D10% could benefit patients in controlling their post-treatment high blood sugar levels.
• Causes of hypoglycemia include medication misuse or overdose, missed meals, infection, cardiovascular insults (e.g., myocardial infarction, arrhythmia), or changes in activity (e.g., exercise).
• Diabetics are not the only persons who become hypoglycemic. Alcoholics, some poisoned patients, and others may develop problems with glucose metabolism.
• Sulfonylurea (e.g., glyburide, glipizide) toxicity can last up to 72 hours. Patients with corrected hypoglycemia who are taking these agents are at particular risk for recurrent hypoglycemia and frequently require hospital admission. These patients should be evaluated in the Emergency Department.
• When administering dextrose, monitor IV site for signs of extravasation.