What is the immediate treatment for a patient experiencing hypoglycemia, particularly one with a history of diabetes?

Treatment of Hypoglycemia

Immediate Treatment for Conscious Patients

For conscious patients with hypoglycemia (blood glucose ≤70 mg/dL), immediately administer 15-20 grams of oral glucose, preferably as glucose tablets or solution, and recheck blood glucose in 15 minutes. 1, 2

• Glucose tablets or solution are the most effective treatment options because pure glucose correlates better with acute glycemic response than total carbohydrate content of foods 2, 3
• Any carbohydrate-containing food with glucose can be used if tablets are unavailable, but avoid foods with added fat (chocolate, candy bars with nuts, milk) as fat retards glucose absorption 2, 3
• Orange juice and glucose gel are less effective in quickly alleviating symptoms compared to glucose tablets or solution 2

Follow-up Protocol After Initial Treatment

• Recheck blood glucose 15 minutes after carbohydrate ingestion 1, 2
• If blood glucose remains below 70 mg/dL or symptoms persist, repeat treatment with another 15-20 grams of carbohydrate 1, 2
• Once blood glucose trends upward above 70 mg/dL, provide a meal or snack containing protein and complex carbohydrates to restore liver glycogen and prevent recurrence 1, 3
• Blood glucose should be evaluated again 60 minutes after initial treatment 2

Special Consideration for Automated Insulin Delivery Systems

• For patients using automated insulin delivery systems, a lower dose of 5-10 grams of carbohydrates may be appropriate unless hypoglycemia occurs with exercise or after significant insulin overestimation 2

Immediate Treatment for Unconscious or Severely Altered Patients

For patients with severe hypoglycemia and altered mental status or unconsciousness, immediately administer 10-20 grams of intravenous 50% dextrose if IV access is available, or 1 mg intramuscular/subcutaneous glucagon if IV access is not available. 1, 3

IV Dextrose Protocol (Preferred if IV Access Available)

• Administer 10-20 grams of hypertonic (50%) dextrose solution intravenously, titrated based on the initial hypoglycemic value 1
• Stop any insulin infusion immediately when treating hypoglycemia 1, 3
• 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
• Recheck blood glucose after 15 minutes 1
• If blood glucose remains below 70 mg/dL, repeat dextrose administration 1
• Continue monitoring every 15 minutes until blood glucose stabilizes above 70 mg/dL 1
• Avoid overcorrection that causes iatrogenic hyperglycemia 1, 3

Glucagon Administration (When IV Access Not Available)

• Glucagon administration is not limited to healthcare professionals—family members and caregivers can and should administer 1 mg intramuscular glucagon into the upper arm, thigh, or buttocks immediately 1, 4
• For adults and pediatric patients weighing more than 25 kg or age ≥6 years: administer 1 mg (1 mL) subcutaneously or intramuscularly 2, 4
• For pediatric patients weighing less than 25 kg or age <6 years: administer 0.5 mg (0.5 mL) subcutaneously or intramuscularly 2, 4
• Newer intranasal and ready-to-inject glucagon preparations are now available and preferred due to ease of administration 2
• If there has been no response after 15 minutes, an additional dose may be administered using a new kit while waiting for emergency assistance 4

Critical Safety Warning

• Never attempt oral glucose in an unconscious patient, as it creates aspiration risk and is 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

Post-Recovery Management

• 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) 1, 3
• Follow with a meal or snack containing protein and complex carbohydrates to restore liver glycogen and prevent recurrence 1, 3
• Call for emergency assistance immediately after administering the dose 4

Documentation and Monitoring

• Document blood glucose before treatment if possible, but do not delay treatment while waiting for confirmation 1, 2
• Continue to monitor blood glucose every 1-2 hours if the patient is on insulin infusion 3
• Target blood glucose greater than 70 mg/dL after treatment 1

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
• Screen for sepsis if any signs of infection are present, as altered mental state with hypoglycemia has 86% specificity for predicting hypoglycemia in septic patients 3

Post-Event Management and Prevention

• Any episode of severe hypoglycemia or recurrent episodes of mild to moderate hypoglycemia requires reevaluation of the diabetes management plan 1, 2
• In cases of unexplained or recurrent severe hypoglycemia, consider admission to a medical unit for observation and stabilization 1, 2
• Prescribe glucagon for home use to all patients at risk of clinically significant hypoglycemia and train family members on administration 1, 2
• Educate patients and caregivers on recognizing early hypoglycemia symptoms 1
• Advise patients to always carry fast-acting glucose sources 1
• Patients should understand situations that increase hypoglycemia risk, including fasting for tests or procedures, delayed or skipped meals, intense exercise, alcohol consumption, sleep, and declining renal function 2

Common Pitfalls to Avoid

• Do not use protein to treat hypoglycemia as it may increase insulin secretion 2
• Avoid adding fat to carbohydrate treatment as it may slow and prolong the acute glycemic response 2
• Do not target overly tight glucose control; aim to keep blood glucose >70 mg/dL 2
• Common iatrogenic triggers include sudden reduction of corticosteroid dose, altered ability to report symptoms, reduced oral intake, inappropriate timing of short-acting insulin in relation to meals, and unexpected interruption of feedings 1