What is the approach to evaluating and managing hypoglycemia (low blood sugar) in the emergency department, particularly in patients with a history of diabetes?

Emergency Department Evaluation and Management of Hypoglycemia

Immediate Assessment and Treatment

For any patient presenting with suspected hypoglycemia, immediately check capillary blood glucose (CBG) and do not delay treatment if hypoglycemia is suspected clinically—treatment takes priority over confirmation. 1, 2

Initial Blood Glucose Check and Treatment Decision

• Check CBG immediately upon arrival to confirm hypoglycemia (defined as blood glucose <60-70 mg/dL). 3, 1
• Do not delay treatment to obtain confirmatory blood glucose if clinical presentation strongly suggests hypoglycemia (altered mental status, diaphoresis, confusion, agitation). 1, 2
• Be aware that hypoglycemia symptoms can mimic intoxication, withdrawal, or head trauma, particularly in patients presenting with altered mental status after trauma. 3, 4

Treatment Based on Mental Status

For conscious patients who can follow commands and swallow safely:

• Administer 15-20 grams of oral glucose immediately (glucose tablets preferred). 1, 2
• Recheck blood glucose every 15 minutes until it stabilizes above 70 mg/dL. 3, 1
• Repeat 15-20 grams of oral glucose at 15-minute intervals if blood glucose remains below 70 mg/dL. 3
• Once stabilized, provide a meal or snack with long-acting carbohydrates to prevent recurrence. 1, 5

For patients with altered mental status, unconsciousness, seizures, or inability to swallow:

• Administer 10-20 grams of IV 50% dextrose immediately, titrated based on the initial hypoglycemic value. 1, 2
• Stop any insulin infusion immediately if present. 1, 2
• If no IV access is available, administer 1 mg glucagon intramuscularly into the upper arm, thigh, or buttocks—this can and should be done by family members or caregivers, not limited to healthcare professionals. 1, 5, 6
• Recheck blood glucose after 15 minutes and repeat dextrose administration if blood glucose remains below 70 mg/dL. 1, 2
• Avoid overcorrection that causes iatrogenic hyperglycemia. 1

Critical Pitfalls to Avoid

• Never attempt oral glucose in unconscious patients or those who cannot safely swallow—this creates aspiration risk and is contraindicated. 1, 2
• 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
• If patient is taking α-glucosidase inhibitors, use ONLY glucose tablets or monosaccharides to treat hypoglycemia, not complex carbohydrates. 2

Risk Stratification and Monitoring

Identify High-Risk Features Requiring Intensive Monitoring

• History of recurrent severe hypoglycemia or hypoglycemia unawareness. 1, 2
• Concurrent illness, sepsis, hepatic failure, or renal failure. 1, 2
• Recent reduction in corticosteroid dose or altered nutritional intake. 1
• Advanced age (>60 years). 2
• Medications: insulin, sulfonylureas, or meglitinides. 3, 2

Monitoring Protocol

• Continue checking blood glucose every 15 minutes until stable above 70 mg/dL. 1, 2
• Monitor for recurrence, especially if a long-acting causative agent (sulfonylureas, long-acting insulin) is involved. 2, 7
• Target blood glucose >70 mg/dL after treatment. 1

Medication Review and Adjustment

Immediate Medication Management

• Stop any insulin infusion if present. 1, 2
• Hold or adjust doses of insulin, sulfonylureas, or meglitinides on admission. 2
• Review all medications that may contribute to hypoglycemia, including over-the-counter drugs. 2, 7

Common Iatrogenic Triggers to Identify

• Sudden reduction of corticosteroid dose. 1
• Altered ability of the patient to report symptoms. 1
• Reduced oral intake, emesis, or new nothing-by-mouth status. 1
• Inappropriate timing of short-acting insulin in relation to meals. 1
• Reduced infusion rate of IV dextrose. 1
• Unexpected interruption of oral, enteral, or parenteral feedings. 1

Post-Stabilization Management and Disposition

Reevaluation of Diabetes Management Plan

• Any episode of severe hypoglycemia or recurrent episodes of mild to moderate hypoglycemia requires reevaluation of the diabetes management plan by medical staff. 3, 1
• In cases of unexplained or recurrent severe hypoglycemia, consider admission to a medical unit for observation and stabilization of diabetes management. 3, 1

Discharge Planning and Patient Education

• Before discharge, ensure medication regimen is reviewed and adjusted to prevent recurrence. 2
• Prescribe glucagon for home use and train family members and caregivers on administration. 1, 2
• Educate patients and caregivers on recognizing early hypoglycemia symptoms (tremor, sweating, confusion, hunger). 1, 2
• Advise patients to always carry fast-acting glucose sources (glucose tablets, regular soft drink, fruit juice). 1, 2
• Recommend medical identification indicating diabetes and hypoglycemia risk. 1
• Educate on situations that increase hypoglycemia risk: fasting for tests or procedures, delayed meals, intense exercise, and sleep. 1

Follow-Up Arrangements

• Arrange appropriate medical follow-up to minimize risk of future decompensation. 3
• Do not discharge patients without follow-up arranged, as this represents suboptimal care. 8

Special Considerations for Non-Diabetic Patients

Diagnostic Evaluation for Non-Diabetic Hypoglycemia

• Confirm true hypoglycemia using Whipple's Triad: low plasma glucose concentration, neurogenic and/or neuroglycopenic symptoms, and resolution of symptoms with normalization of glucose. 7
• Obtain plasma glucose, insulin level, C-peptide level, proinsulin level, and sulfonylurea/meglitinide screen when hypoglycemia is documented in non-diabetic patients. 7
• Consider insulinoma or other insulin-secreting tumor in patients with recurrent unexplained hypoglycemia. 7