What is the best course of treatment for a patient experiencing insulin shock due to hypoglycemia (low blood sugar)?

Treatment of Insulin Shock (Severe Hypoglycemia)

For a patient experiencing insulin shock with altered mental status, immediately administer 10-20 grams of intravenous 50% dextrose if IV access is available, or 1 mg intramuscular glucagon if not, then recheck blood glucose in 15 minutes and repeat dosing until blood glucose exceeds 70 mg/dL. 1, 2, 3

Immediate Management Based on Patient Consciousness

Unconscious or Seizing Patient (Level 3 Hypoglycemia)

If IV access is available:

• Administer 10-20 grams of hypertonic (50%) dextrose solution intravenously immediately, titrated based on the initial hypoglycemic value 1, 2
• Stop any insulin infusion if present 1
• Recheck blood glucose after 15 minutes 1, 2
• If blood glucose remains below 70 mg/dL, repeat dextrose administration 1, 2
• Continue monitoring every 15 minutes until blood glucose stabilizes above 70 mg/dL 1

If IV access is NOT available:

• Immediately administer 1 mg (1 mL) glucagon intramuscularly into the upper arm, thigh, or buttocks for adults and children weighing >25 kg or ≥6 years 2, 3
• For children weighing <25 kg or <6 years, administer 0.5 mg (0.5 mL) glucagon 3
• Call emergency medical services immediately after administering glucagon 3
• Family members and caregivers can and should administer glucagon—healthcare professional status is not required 4, 2
• Newer intranasal and ready-to-inject glucagon preparations are preferred due to ease of administration 4, 2
• If no response after 15 minutes, administer an additional dose using a new kit while waiting for emergency assistance 3

Conscious Patient with Mild-to-Moderate Hypoglycemia

• Administer 15-20 grams of oral glucose, preferably as glucose tablets, as first-line treatment 5, 2
• Pure glucose is preferred because the glycemic response correlates better with glucose content than total carbohydrate content 4, 5
• Any carbohydrate-containing food with glucose can serve as an alternative if glucose tablets are unavailable 5, 2
• Recheck blood glucose after 15 minutes 5, 2
• If hypoglycemia persists (glucose still <70 mg/dL), repeat treatment with another 15-20 grams of carbohydrate 5, 2
• Once blood glucose normalizes, the patient should consume a meal or snack to prevent recurrence 4, 2

Critical Treatment Principles

Never attempt oral glucose in an unconscious patient—this creates aspiration risk and is absolutely contraindicated. 1

Avoid these common errors:

• Do not use protein sources (like milk or peanut butter) to treat hypoglycemia, as protein may increase insulin secretion without raising glucose 4, 5
• Do not add fat to carbohydrate treatment, as it slows and prolongs the glycemic response 4, 5
• Do not use buccal glucose as first-line treatment—it is less effective than swallowed glucose in conscious patients and inappropriate for unconscious patients 1
• Avoid overcorrection that causes iatrogenic hyperglycemia 1

Post-Treatment Monitoring and Prevention

Target blood glucose after treatment:

• Achieve blood glucose greater than 70 mg/dL 1
• For hospitalized critically ill patients, maintain target range of 140-180 mg/dL 1
• For noncritically ill hospitalized patients, target 100-180 mg/dL 1

Mandatory follow-up actions:

• Any episode of severe hypoglycemia or recurrent episodes of mild-to-moderate hypoglycemia requires reevaluation of the diabetes management plan 1, 5, 2
• Patients with hypoglycemia unawareness or one level 3 hypoglycemic event should raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks to partially reverse hypoglycemia unawareness 4, 2
• In cases of unexplained or recurrent severe hypoglycemia, consider admission to a medical unit for observation and stabilization 1, 5

High-risk features requiring intensive monitoring:

• History of recurrent severe hypoglycemia or hypoglycemia unawareness 1
• Concurrent illness, sepsis, hepatic failure, or renal failure 1
• Recent reduction in corticosteroid dose or altered nutritional intake 1

Patient and Caregiver Education

Prescribe glucagon for home use and ensure:

• Family members and caregivers are trained on glucagon administration, including where it is kept and when and how to administer it 4, 5
• Patients always carry fast-acting glucose sources 1
• Patients understand high-risk situations: fasting for tests, delayed meals, intense exercise, alcohol consumption, and sleep 5
• Medical identification indicating diabetes and hypoglycemia risk is worn 1

Special Considerations

Glucagon will NOT work effectively in:

• Patients in states of starvation 3
• Patients with adrenal insufficiency 3
• Patients with chronic hypoglycemia who may not have adequate hepatic glycogen stores 3
• These patients should be treated with intravenous glucose instead 3

Contraindications to glucagon:

• Patients with insulinoma (may cause paradoxical hypoglycemia after initial glucose rise) 3
• Patients with glucagonoma when used as a diagnostic aid 3
• Prior hypersensitivity reaction to glucagon 3