HYPOGLYCEMIA

Question 1

Approach to the Critically Ill Hypoglycemic Patient

Answer 1

A - stridor
B - RR 30, 02 sats 90% on Fi02 30%
C - mottled appearance. VOLUME STATUS. Cap refill. Pulses.
D - CHECK GLUCOSE. GCS, PERRLA & lateralizing signs.
E - Exposure, take down dressings. LOOK FOR SIGNS OF INCITING INFECTION.

Monitor
O2 Target to 94%
Vitals
IV Access: 2 large bore IV
Equipment for Airway and ECG

Correct Hypoglycemia for the Seizing of Obtunded Patient:

Dextrose 50% 50 mL (25 g) IV/IO

Dextrose 10% 250 mL (25 g) IV/IO

Glucagon 1 mg intramuscular (IM) for patients without IV/IO access.

oral glucose if the patient is able to swallow

Sulfonylurea, administer
Octreotide 50-100 μg, subcutaneous (SC) or IV

Note: octreotide should be administered after dextrose bolus – do not delay glucose correction to give octreotide.

Perform fingerstick glucose checks every hour until glucose is maintained

Question 2

Etiology

Answer 2

Poor PO Intake
Medications
Infection / Ischemia (rare)

Question 3

Diagnosis: Whipple’s Triad

Answer 3

Symptoms consistent with hypoglycemia

low glucose level

relief of the symptoms when glucose is replenished

Question 4

Management: Obtunded or Seizing with IV Access - Adults & Children > 8 y, Children 2 mo - 8 y, Children < 2 mo

Answer 4

Adults and children over 8 y:

Dextrose 50% (D50W) 50 mL (25 g) (1 ampule) in adults, IV bolus
OR
0.5-1 g/kg (1-2 mL/kg in children >8 y of age)

Children 2 mo - 8 y:

Dextrose 25% (D25W) 0.5-1 g/kg (2-4 mL/kg) IV bolus

Children < 2 mo:

D10W: 0.5-1 g/kg (5-10 mL/kg) IV bolus

Document the time of onset and interventions

Check fingersticks every hour until glucose is maintained without intervention.

If hypoglycemia recurs, administer dextrose IV bolus and start a maintenance infusion of D10W.

Question 5

Management: Obtunded or Seizing WITHOUT IV Access - > 20 kg, < 20 kg

Answer 5

Weight >20 kg

glucagon 1 mg IM

May repeat in 15 min

Weight <20 kg

glucagon 0.5 mg IM

May repeat in 15 min

Note: requires adequate glycogen stores, which may be absent in malnourished patients

Document the time of onset and interventions

Check fingersticks every hour until glucose is maintained without intervention.

If hypoglycemia recurs, administer dextrose IV bolus and start a maintenance infusion of D10W.

Question 6

Management: Sulfonurea - Adults, Children

Answer 6

Adults: Octreotide 50-100 μg, subcutaneous (SC) or IV

Children: Octreotide 1 μg/kg (max 50 μg) SC preferred but can be given IV q6-12h

Note: octreotide should be administered after dextrose bolus – do not delay glucose correction to give octreotide.

Contact poison control center or a medical toxicologist for guidance

Check fingersticks every hour until glucose is maintained without intervention.

If hypoglycemia recurs, administer dextrose IV bolus and start a maintenance infusion of D10W.

24 hours of monitored observation. If patients receive octreotide, observation should continue until 24 hours after the last dose of octreotide.