Hypoglycemia Treatment Protocol
Immediately administer 15-20 grams of oral glucose for conscious patients with blood glucose ≤70 mg/dL, recheck in 15 minutes, and repeat if needed; for unconscious or severely altered patients, give 10-20 grams of IV 50% dextrose or 1 mg intramuscular/subcutaneous glucagon, then provide oral carbohydrates once the patient can swallow safely. 1, 2, 3
Conscious Patient Protocol
Initial Treatment
- Give 15-20 grams of oral glucose immediately when blood glucose is ≤70 mg/dL 2
- Pure glucose tablets or glucose solution are preferred over other carbohydrate sources because the glycemic response correlates better with glucose content 2
- Any glucose-containing carbohydrate can be used if glucose tablets are unavailable, though orange juice and glucose gel are less effective at quickly alleviating symptoms 2
- Do not use protein to treat hypoglycemia as it may increase insulin secretion 2
- Adding fat to carbohydrate treatment may slow and prolong the acute glycemic response 2
Monitoring and Repeat Dosing
- Recheck blood glucose after 15 minutes 1, 2
- If blood glucose remains below 70 mg/dL, repeat treatment with another 15-20 grams of carbohydrate 1, 2
- Continue monitoring every 15 minutes until blood glucose stabilizes above 70 mg/dL 1
- Evaluate blood glucose again 60 minutes after initial treatment 2
Special Consideration for Automated Insulin Delivery
- Patients using automated insulin delivery systems may only need 5-10 grams of carbohydrates unless hypoglycemia occurs with exercise or after significant insulin overestimation 2
Severe Hypoglycemia Protocol (Unconscious or Unable to Swallow)
Immediate Management
- Administer 10-20 grams of IV 50% dextrose immediately, titrated based on the initial hypoglycemic value 1, 4
- Stop any insulin infusion immediately if present 1, 4
- Document blood glucose before treatment if possible, but never delay treatment while waiting for confirmation 5, 2
- 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 1
Glucagon Administration (When IV Access Unavailable)
- Administer 1 mg (1 mL) glucagon intramuscularly or subcutaneously into the upper arm, thigh, or buttocks for adults and children weighing >25 kg or ≥6 years 1, 3
- Administer 0.5 mg (0.5 mL) glucagon for children weighing <25 kg or <6 years 1, 3
- Family members and caregivers can and should administer glucagon—it is not limited to healthcare professionals 1, 4
- Newer intranasal and ready-to-inject glucagon preparations are preferred due to ease of administration 2, 6
- Recovery of consciousness after glucagon is slower than after IV dextrose (6.5 vs. 4.0 minutes), though both are effective 7
Post-Treatment Management
- Call for emergency assistance immediately after administering the dose 3
- If no response after 15 minutes, administer an additional dose using a new kit while waiting for emergency assistance 3
- Once the patient regains consciousness and can safely swallow, immediately give oral fast-acting carbohydrates (15-20 grams of glucose, regular soft drink, or fruit juice), followed by long-acting carbohydrates to restore liver glycogen and prevent recurrence 1, 3
Critical Pitfalls to Avoid
- Never attempt oral glucose in an unconscious patient—it creates aspiration risk and is absolutely contraindicated 1
- Do not use buccal glucose as first-line treatment, as it is less effective than swallowed glucose in conscious patients and inappropriate for unconscious patients 1
- Avoid overcorrection that causes iatrogenic hyperglycemia by titrating dextrose carefully 1, 4
- Failing to stop insulin infusions will perpetuate hypoglycemia despite glucose replacement 4
- Do not use complex carbohydrates in patients on α-glucosidase inhibitors, as it delays treatment effectiveness 4
Hospital-Specific Protocols
Standardized Institutional Response
- A standardized hospital-wide and nurse-initiated hypoglycemia treatment protocol must be in place to immediately address hypoglycemia 5
- Hospital-related hypoglycemia is associated with higher mortality 5
- Train all correctional and security staff who supervise patients at risk for hypoglycemia in recognition, treatment, and appropriate referral 5
- Train appropriate staff to administer glucagon 5
- Implement a policy requiring staff to notify a physician of all blood glucose results outside of a specified range (e.g., <50 or >350 mg/dL) 5
Common Iatrogenic Triggers
- Sudden reduction of corticosteroid dose 5
- Altered ability of the patient to report symptoms 5
- Reduced oral intake, emesis, or new nothing-by-mouth status 5
- Inappropriate timing of short-acting insulin in relation to meals 5
- Reduced infusion rate of IV dextrose 5
- Unexpected interruption of oral, enteral, or parenteral feedings 5
Post-Event Management and Prevention
Immediate Reassessment
- Any episode of severe hypoglycemia or recurrent episodes of mild to moderate hypoglycemia requires reevaluation of the diabetes management plan 5, 4, 2
- In cases of unexplained or recurrent severe hypoglycemia, consider admission to a medical unit for observation and stabilization 5, 4
Prevention Strategy
- Raise glycemic targets for at least several weeks to strictly avoid further hypoglycemia, which partially reverses hypoglycemia unawareness and reduces risk of future episodes 4
- Implement continuous glucose monitoring (CGM) for high-risk patients and increase frequency of self-monitoring blood glucose 4
- Adjust medication regimens, particularly insulin dosing and sulfonylurea use 4
- Coordinate medication administration with meal timing to minimize risk 4
Patient and Caregiver Education
- Educate patients and caregivers on recognizing early hypoglycemia symptoms 1
- Prescribe glucagon for home use and train family members on administration 1
- Advise patients to always carry fast-acting glucose sources 1
- Recommend medical identification indicating diabetes and hypoglycemia risk 1
- Instruct patients on situations that increase hypoglycemia risk: fasting for tests or procedures, delayed or skipped meals, intense exercise, alcohol consumption, sleep, and declining renal function 2
High-Risk Patient Identification
Patients requiring intensive monitoring include those with: 1
- History of recurrent severe hypoglycemia or hypoglycemia unawareness
- Concurrent illness, sepsis, hepatic failure, or renal failure
- Recent reduction in corticosteroid dose
- Altered nutritional intake
Consider housing high-risk patients closer to medical units to minimize treatment delays 2