What is the immediate treatment for hypoglycemia (low blood sugar) in the emergency department?

Immediate Treatment of Hypoglycemia in the Emergency Department

For conscious patients able to swallow, immediately administer 15-20 grams of oral glucose (preferably glucose tablets) and recheck blood glucose in 15 minutes; for unconscious patients, those with seizures, or those unable to follow commands, administer 10-20 grams of intravenous 50% dextrose immediately or 1 mg intramuscular glucagon if IV access is unavailable. 1, 2

Triage and Initial Assessment

The first critical decision point is determining the patient's level of consciousness and ability to swallow safely:

• Severe hypoglycemia is defined by unconsciousness, seizures, or inability to follow simple commands—this is a medical emergency requiring immediate intervention 3, 1, 2
• Mild-to-moderate hypoglycemia presents with confusion, altered behavior, diaphoresis, or tremulousness in a patient who remains conscious and can swallow 3, 1
• Blood glucose ≤70 mg/dL with altered mental status constitutes severe hypoglycemia requiring emergency treatment 2

Treatment Algorithm for Conscious Patients

First-Line Treatment

• Administer 15-20 grams of oral glucose immediately using glucose tablets as the preferred formulation 1, 2
• Glucose tablets provide more rapid clinical relief compared to dietary sugars like candy, orange juice, or milk 3
• If glucose tablets are unavailable, alternative dietary sugars (sucrose-containing foods, juice) are reasonable substitutes 3

Monitoring and Repeat Dosing

• Recheck blood glucose after 10-15 minutes 3, 1
• If blood glucose remains below 70 mg/dL or symptoms persist, repeat the 15-20 gram oral glucose dose 1, 4
• Continue this cycle until blood glucose levels normalize 1
• Symptoms may not resolve until 10-15 minutes after glucose ingestion—avoid premature re-treatment 3

Post-Recovery Care

• Once glucose normalizes, provide a meal or snack containing long-acting carbohydrates to prevent recurrence 2, 4

Treatment Algorithm for Unconscious or Severely Altered Patients

Intravenous Dextrose (Preferred if IV Access Available)

• Administer 10-20 grams of intravenous 50% dextrose immediately 2, 4
• A 25-gram IV dextrose dose produces blood glucose increases of approximately 162 mg/dL at 5 minutes and 63.5 mg/dL at 15 minutes 2
• Recent evidence shows no difference in efficacy between 10%, 25%, and 50% dextrose concentrations in achieving baseline mental status (all achieve GCS 15 in median 6 minutes), but lower concentrations (10% and 25%) require less total dextrose (10-15g vs 15-25g) 5
• Stop any insulin infusion if present 2, 4

Intramuscular Glucagon (If IV Access Unavailable)

• Administer 1 mg intramuscular glucagon into the upper arm, thigh, or buttocks 2, 6
• For pediatric patients weighing less than 25 kg or under 6 years of age, administer 0.5 mg 6
• Family members and caregivers can and should administer glucagon—this is not limited to healthcare professionals 2, 6
• Recovery of consciousness after glucagon is slower than after dextrose (6.5 minutes vs 4.0 minutes) but remains effective 7
• Intranasal glucagon resulted in substantial improvement in 32% of prehospital cases, with mean blood glucose increase of 53.3 mg/dL in responders 8

Monitoring Protocol

• Recheck blood glucose every 15 minutes until levels exceed 70 mg/dL 2, 4
• If blood glucose remains below 70 mg/dL after 15 minutes, repeat dextrose administration 2
• If using glucagon and no response occurs after 15 minutes, an additional dose may be administered using a new kit while waiting for emergency assistance 6

Post-Recovery Oral Carbohydrates

• Once the patient regains consciousness and can safely swallow, immediately give 15-20 grams of oral fast-acting carbohydrates (glucose tablets, regular soft drink, or fruit juice), followed by long-acting carbohydrates 2

Target Blood Glucose After Treatment

• Achieve blood glucose greater than 70 mg/dL 2, 4
• Avoid overcorrection causing iatrogenic hyperglycemia 2, 4
• For hospitalized noncritically ill patients, maintain target range of 100-180 mg/dL 2, 4
• For critically ill patients, maintain 140-180 mg/dL 2

Critical Pitfalls to Avoid

• Never attempt oral glucose in an unconscious patient—this creates aspiration risk and is absolutely contraindicated 2
• Do not use buccal glucose as first-line treatment in conscious patients, as it is less effective than swallowed glucose 1, 2
• Do not delay treatment to document blood glucose if severe hypoglycemia is clinically evident, though document when possible 2
• Do not wait longer than 10-15 minutes before re-treating or escalating care 3, 1

High-Risk Features Requiring Intensive Monitoring

Patients with the following characteristics require closer observation and may need admission rather than discharge:

• History of recurrent severe hypoglycemia or hypoglycemia unawareness 2
• Concurrent illness, sepsis, hepatic failure, or renal failure 2
• Recent reduction in corticosteroid dose or altered nutritional intake 2

Disposition and Follow-Up

Current management of hypoglycemia in emergency departments is often suboptimal—90% of hypoglycemic patients are discharged from the ED, and half have no follow-up arranged 9. Before discharge:

• Educate the patient and caregivers on recognizing early hypoglycemia symptoms 2
• Prescribe glucagon for home use and train family members on administration 2
• Advise patients to always carry fast-acting glucose sources 2
• Recommend medical identification indicating diabetes and hypoglycemia risk 2
• Arrange appropriate follow-up with primary care or endocrinology 9