What is the immediate management for a patient in hypoglycaemic coma?

Management of Hypoglycaemic Coma

For a patient in hypoglycaemic coma (unconscious, unable to follow commands, or seizing), immediately administer 10-20 grams of intravenous 50% dextrose, stop any insulin infusion if present, and if IV access is unavailable, give 1 mg intramuscular glucagon into the upper arm, thigh, or buttocks. 1, 2

Immediate Assessment and Treatment Algorithm

Step 1: Confirm Hypoglycemia and Assess Consciousness

• Check blood glucose immediately to confirm diagnosis, but do not delay treatment if hypoglycemia is clinically suspected 1, 2
• Assess the patient's level of consciousness and ability to swallow safely 1

Step 2: Treatment Based on Consciousness Level

For Unconscious/Comatose Patients (Cannot Follow Commands or Seizing):

• Administer 10-20 grams of IV 50% dextrose immediately, titrated based on initial glucose value 1, 2
• Stop any insulin infusion if present 1, 3
• If no IV access is available: Give 1 mg glucagon intramuscularly into the upper arm, thigh, or buttocks 2, 4
  • For children weighing <25 kg or <6 years: Give 0.5 mg (0.5 mL) glucagon 4
• Never attempt oral glucose in an unconscious patient due to aspiration risk 2

For Conscious Patients Who Can Swallow:

• Administer 15-20 grams of oral glucose immediately (glucose tablets preferred) 5, 1, 2
• If patient is taking α-glucosidase inhibitors, use ONLY glucose tablets or monosaccharides (not complex carbohydrates) 1, 3

Step 3: Monitoring and Repeat Dosing

• Recheck blood glucose every 15 minutes until it stabilizes above 70 mg/dL 1, 3, 2
• If blood glucose remains below 70 mg/dL after 15 minutes, repeat dextrose administration 3, 2
• If using glucagon and no response after 15 minutes, administer an additional dose using a new kit while waiting for emergency assistance 4
• Avoid overcorrection causing iatrogenic hyperglycemia by titrating dextrose carefully 3, 2

Step 4: 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) 2
• Follow with a meal or snack containing long-acting carbohydrates to restore liver glycogen and prevent recurrence 5, 2, 4

Critical Medication Management

• Stop insulin infusions immediately if present—failing to do so will perpetuate hypoglycemia despite glucose replacement 1, 3
• Hold or adjust doses of insulin, sulfonylureas, or meglitinides 1
• Review all medications that may contribute to hypoglycemia 1

Glucagon Administration Details

Glucagon can and should be administered by family members and caregivers—it is not limited to healthcare professionals 5, 2, 4

Preparation and Dosing:

• Using the supplied prefilled syringe, inject all liquid into the vial containing glucagon powder 4
• Shake gently until completely dissolved and clear 4
• The reconstituted solution is 1 mg per mL glucagon 4
• Adults and children >25 kg or ≥6 years: 1 mg (1 mL) IM/SC 4
• Children <25 kg or <6 years: 0.5 mg (0.5 mL) IM/SC 4
• Call for emergency assistance immediately after administering 4

Comparative Efficacy: Recovery of consciousness after glucagon is slower than after IV dextrose (6.5 vs. 4.0 minutes), though both are effective 6

High-Risk Features Requiring Intensive Monitoring

Identify patients at increased risk for recurrent severe hypoglycemia: 1, 2

• History of recurrent severe hypoglycemia or hypoglycemia unawareness
• Concurrent illness, sepsis, hepatic failure, or renal failure
• Recent reduction in corticosteroid dose or altered nutritional intake
• Advanced age (>60 years)
• Medications: insulin, sulfonylureas, or insulin secretagogues

Common Iatrogenic Triggers to Avoid

Hospital-related hypoglycemia is associated with higher mortality, so be vigilant for: 2

• Sudden reduction of corticosteroid dose
• Reduced oral intake, emesis, or new NPO status
• Inappropriate timing of short-acting insulin in relation to meals
• Reduced infusion rate of IV dextrose
• Unexpected interruption of oral, enteral, or parenteral feedings

Post-Stabilization and Discharge Planning

Any episode of severe hypoglycemia requires reevaluation of the diabetes management plan 3, 2

Before Discharge:

• Review and adjust medication regimen to prevent recurrence 1
• Prescribe glucagon for home use and train family members/caregivers on administration 5, 1, 2
• Educate patient and caregivers on recognizing early hypoglycemia symptoms 1, 2
• Advise patient to always carry fast-acting glucose sources 5, 2
• Recommend medical identification (bracelet/necklace) indicating diabetes and hypoglycemia risk 5, 2

For Patients with Hypoglycemia Unawareness:

• Raise glycemic targets for at least several weeks to strictly avoid further hypoglycemia, which partially reverses hypoglycemia unawareness and reduces risk of future episodes 5, 3

Special Considerations for Sulfonylurea-Induced Hypoglycemia

Hypoglycemic coma due to sulfonylurea overdose always requires hospitalization for careful supervision and prolonged intravenous glucose infusion, as the duration of action is much longer than insulin 7

Target Blood Glucose Post-Treatment

• Achieve blood glucose >70 mg/dL 1, 2
• For hospitalized critically ill patients: maintain 140-180 mg/dL 2
• For noncritically ill patients: target 100-180 mg/dL 2