Hypoglycaemia

UNCONTROLLED WHEN PRINTED

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Introduction

When the Blood Glucose Level (BGL) falls below that required for optimal physiological function, (usually < 4mmol/L) with demonstrable signs or symptoms.

Clinical Presentation

Exclusion Criteria

Risk Assessment

Always treat diabetics with altered conscious state as having hypoglycaemia, as well as any other problems (extra glucose won't worsen the hyperglycaemia, and saves the life of the unconscious hypoglycaemic).
Diabetic patients taking Glucobay (Acarbose) have a greater glucose requirement due to stimulation of pancreatic insulin release.
Consider the aetiology of hypoglycaemia when selecting the most appropriate treatment (eg: glucagon will be ineffective in the absence of adequate hepatic glycogen stores).
Chronic poorly controlled diabetes may be hypoglycaemic despite a BGL >4mmol/L.
Encourage transport post treatment.
Hypoglycaemia may present as a focal neurological deficit or coma.
All patients with an altered GCS (i.e. abnormal for the individual) should have a BGL test preformed and managed appropriately if symptomatic.
IV boluses of glucose may need to be repeated when the patient remains hypoglycaemic due to an Insulin overdose (accidental/intentional), the objective is to achieve normoglycaemia, GCS may not improve.
Hypoglycaemia may present as a focal neurological deficit or coma.
Encourage transport post treatment.
Where intentional overdose is suspected the patient should be transferred to a healthcare facility, seek WAPOL support if required.

Management

Primary Care

Primary Survey
- Insert airway adjunct and assist ventilations as required
Consider Oxygen as per CPG
Reassurance (continuous)
Vital Sign Survey (monitor regularly including pre-and-post intervention blood glucose levels)
- Monitor closely SpO₂, GCS and BGL
If conscious state allows (i.e. GCS 15/15):
- Give glucose drink or food (oral carbohydrates).
- Consider administering Glucose Oral Gel as per instructions on package
- Reassess GCS and BGL after 10 minutes
- Follow up as needed with complex carbohydrates (e.g. sandwich)

Intermediate Care (EMT / Level 2)

If altered level of consciousness:
- Give Glucose Oral Gel if indicated; squeeze small amount of gel at a time into the cheek pouch.
- If patient does not improve after 10 minutes or deteriorates, reassess GCS and BGL
- Administer 2nd dose of Glucose Oral Gel if indicated
Consider applying cardiac monitor if trained and authorised
Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
Transport Priority 1 if patient time critical, pre-notifying receiving facility

Advanced Care (AP)

If GCS does not permit oral intake:
- Establish vascular access (if readily obtainable); administer intravenous glucose 10% as per CPG
- OR
- If IV access is delayed or not obtainable, administer intramuscular glucagon as per CPG
Reassess GCS and BGL after 10 minutes
If the BGL is still low and the patient symptomatic:
- Encourage oral intake of complex carbohydrates, patient condition permitting
- OR
- Administer repeat dose of intravenous glucose 10% as per CPG
- OR
- Administer repeat dose of intramuscular glucagon as per CPG
Consider cardiac monitoring
Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
Transport Priority 1 if patient time critical, pre-notifying receiving facility

Critical & Extended Care (CCP, PSO)

Additional Information

Seizure
Coma
Brain Damage
Patients with insulin overdose will require frequent assessments, paying close attention to blood glucose levels and being aware of ECG changes.

References

Key Terms & Links

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