How to manage severe hypoglycemia without IV access?

Management of Severe Hypoglycemia Without IV Access

For severe hypoglycemia (BGL 2.8) without IV access, administer glucagon 0.5-1.0 mg intramuscularly as the primary treatment option. 1

Initial Assessment and Treatment Algorithm

For Conscious Patients

• Immediately administer 15-20g of oral glucose (glucose tablets preferred if available) 1
• Monitor blood glucose every 15 minutes until levels rise above 3.9 mmol/L 1
• Once blood glucose is >3.9 mmol/L, provide starchy or protein-rich foods if the next meal is more than an hour away 1

For Patients with Cognitive Impairment or Unable to Swallow

• Administer glucagon 0.5-1.0 mg intramuscularly (IM) into upper arm, thigh, or buttocks 1, 2
• Dosage considerations:
  • Adults and children >25kg or ≥6 years: 1 mg IM 2
  • Children <25kg or <6 years: 0.5 mg IM 2
• If no response after 15 minutes, a second dose may be administered while waiting for emergency assistance 2
• For children who are awake but unwilling to swallow glucose, consider applying a slurry of granulated sugar and water under the tongue 1

Practical Considerations

Glucagon Administration

• Ensure glucagon emergency kits are available for patients at risk of severe hypoglycemia 1
• Train caregivers or family members on proper administration of glucagon 1
• Reconstitute glucagon immediately before use by injecting the supplied diluent into the vial containing glucagon powder 2
• Shake gently until completely dissolved and inject immediately 2

When to Seek Emergency Medical Services

• Activate emergency medical services if: 1
  • The patient is unable to swallow
  • The patient has a seizure
  • No improvement occurs within 10 minutes of treatment
  • Hypoglycemia is severe and persistent

Prevention of Recurrence

• Once the patient recovers, investigate the cause of hypoglycemia and adjust medications as needed 1
• Consider relaxing glycemic targets temporarily for patients with recurrent hypoglycemia 1
• For patients with hypoglycemia unawareness, recommend a 2-3 week period of scrupulous avoidance of hypoglycemia 1, 3
• Educate patients to carry emergency glucose sources and identification at all times 1

Special Considerations

• Severe hypoglycemia can lead to seizures, permanent brain injury, and death if untreated 1, 4
• Patients with gastroparesis or other conditions affecting absorption may require alternative routes of glucose administration 4
• Hypoglycemia unawareness increases risk of severe episodes and requires special attention to prevention 3
• Repeated episodes of hypoglycemia can lead to hypoglycemia-associated autonomic failure, creating a vicious cycle of recurrent episodes 3

By following this algorithm, severe hypoglycemia can be effectively managed even without IV access, with glucagon IM injection being the most reliable option for unconscious or cognitively impaired patients.