• Insulin is a regulatory anabolic protein hormone that lowers blood glucose levels by binding to insulin receptors to increase glucose uptake, inhibit hepatic glucose output and promote glycogen production.
  • An additional use for insulin is in combination with a dextrose infusion to help lower potassium levels in hyperkalaemia. Insulin causes an intracellular shift of potassium by stimulating sodium influx; exchanging intracellular sodium for extracellular potassium through activation of the Na+ - K+ -ATPase transporter. IV insulin is believed to cause a dose-dependent decrease in serum potassium, with 10 units estimated to lower serum potassium by 0.6 to 1.2 mEq/L. When administered intravenously, the potassium shifting effects of insulin occur within 15 min of administration1.
  • High-dose insulin and glucose therapy is also an effective treatment for severe beta blocker and calcium channel-blocker poisoning, with studies showing greater efficacy in terms of haemodynamic stability than with conventional treatment2.
  • Diabetic ketoacidosis (DKA)
  • Hyperosmolar hyperglycaemic syndrome (HSS)

In conjunction with glucose:

  • Hyperkalaemia
  • Severe beta-blocker and calcium channel-blocker toxicity
  • Hypoglycaemia
 Precautions / Notes
  • Rapid correction of hyperglycaemia may contribute to cerebral oedema and electrolyte imbalances
  • Hypoglycaemia may occur if insulin dose is too high in relation to insulin requirement
  • Hypoglycaemia may occur during treatment of hyperkalaemia and beta-blocker and calcium channel-blocker toxicity despite concurrent infusion of glucose, and blood glucose should be monitored regularly
 Weight-based Calculations
Cefazolin for fractures/prophylaxis
Presentation: /mL
Calculated dose:  in

ASMA Approval required
Diabetic ketoacidosis (DKA) and Hyperosmolar Hyperglycaemic Syndrome (HSS)
Mix 50 units (0.5ml) Actrapid with 49.5ml 0.9% sodium chloride in a 50ml syringe to achieve a final concentration of 1 unit/ml. Label syringe and administer via syringe driver.

Note: Management of DKA / HSS requires I-STAT


Blood Glucose Level (mmol/L) Infusion dose (50 units in 50ml)
5 or less 0 units/hour (ml/hr)
5.1 – 10 1 units/hour (ml/hr)
10.1 – 15 2 units/hour (ml/hr)
15.1 – 20 3 units/hour (ml/hr)
20.1 – 25 4 units/hour (ml/hr)
Greater than 25 5 units/hour (ml/hr)
Hyperkalaemia (K+ >6.5)
Mix 10 units (0.1ml) of Actrapid with 49.9ml of 50% glucose in a 50ml syringe to achieve a final concentration of 0.2 units/ml. Label syringe and administer via syringe driver
  • 10 units of Actrapid with 50ml of 50% glucose over 15 minutes
  • Repeat as necessary to lower K+ to < 6.5 mEq/L
Beta-blocker or Calcium channel-blocker Toxicity
Mix 50 units (0.5ml) Actrapid with 49.5ml 0.9% sodium chloride in a 50ml syringe to achieve a final concentration of 1 unit/ml. Label syringe and administer via syringe driver.

This antidote is only administered to critically ill patients with:

  • Hypotension (SBP <90mmHg) despite fluid challenge and atropine administration
  • Bradycardia < 60 unresponsive to atropine
  • 2nd or 3rd degree Conduction blocks
  • Commence therapy by administering 25g glucose (50ml of 50% solution)
  • Administer Actrapid 1 unit/kg as an IV bolus

If required:

  • Ongoing infusion of 25g glucose (50ml of 50% solution/hr) to maintain BSL 5.5-14mmol/L)
  • Ongoing infusion of Actrapid 0.5units/kg/hr IV

Infusion table for ongoing treatment of beta-blocker/calcium channel-blocker toxicity

Patient weight (kg) Infusion rate (0.5units/kg/hr) (ml/h)
50 25u/hr (12.5ml/hr)
60 30u/hr (15ml/hr)
70 35u/hr (17.5ml/hr)
80 40u/hr (20ml/hr)
90 45u/hr (22.5ml/hr)
100 50u/hr (25ml/hr)
 Special Considerations
  • Monitor carefully for signs of hypoglycaemia every 20 minutes for the 1st hour in high-dose insulin therapy.
  • Actrapid human insulin (rys) 1000IU in 10mL (100IU/mL) injection multidose vial
Current mode:
Extended Care:
Colour assist:


Moussavi K, Fitter S, Gabrielson SW et al. 2019. Management of hyperkalaemia with insulin and glucose: pearls for the emergency clinician. The Journal of emergency Medicine;57(1):36-42

Engebretsen KM, Kaczmarek KM, Morgan J & Holger JS. 2011. High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning. Clinical Toxicology:49:277-283

Queensland Ambulance Service DKA protocol.

Wyatt JP, Taylor RG, deWit K, Hotton EJ. 2020. Management of hyperkalaemia. In: Oxford Handbook of Emergency Medicine (5th ed). Oxford University Press.

Murray L, Little M, Pascu O, Hoggett K. 2015. high dose insulin therapy. In: Toxicology Handbook (3rd ed). Elsevier

Nickson CP, & Little M (2009). Early use of high-dose insulin euglycaemic therapy for verapamil toxicity. The Medical journal of Australia, 191 (6), 350-2

Document Control

Clinical Services

Responsible Manager
Head of Clinical Services


Issue Date

Expiry Date

Clinical Resources Website

St John Ambulance Western Australia Ltd (ABN 55 028 468 715) (St John WA) operates ambulance and other pre-hospital clinical services. St John WA’s Clinical Resources, including its Clinical Practice Guidelines (Clinical Resources), are intended for use by credentialed St John WA staff and volunteers when providing clinical care to patients for or on behalf of St John WA, within the St John WA Clinical Governance Framework, and only to the extent of the clinician’s authority to practice.

Other users – Terms of Use

The content of the St John WA Clinical Resources is provided for information purposes only and is not intended to serve as health, medical or treatment advice. Any user of this website agrees to be bound by these Terms of Use in their use of the Clinical Resources.

St John WA does not represent or warrant (whether express, implied, statutory, or otherwise) that the content of the Clinical Resources is accurate, reliable, up-to-date, complete or that the information contained is suitable for your needs or for any particular purpose. You are responsible for assessing whether the information is accurate, reliable, up-to-date, authentic, relevant, or complete and where appropriate, seek independent professional advice.

St John WA expressly prohibits use of these Clinical Resources to guide clinical care of patients by organisations external to St John WA, except where these organisations have been directly engaged by St John WA to provide services. Any use of the Clinical Resources, with St John WA approval, must attribute St John WA as the creator of the Clinical Resources and include the copyright notice and (where reasonably practicable) provide a URL/hyperlink to the St John WA Clinical Resources website. 

No permission or licence is granted to reproduce, make commercial use of, adapt, modify or create derivative works from these Clinical Resources. For permissions beyond the scope of these Terms of Use, including a commercial licence, please contact medservices@stjohnambulance.com.au

Where links are provided to resources on external websites, St John WA:

  • Gives no assurances about the quality, accuracy or relevance of material on any linked site;
  • Accepts no legal responsibility regarding the accuracy and reliability of external material; and
  • Does not endorse any material, associated organisation, product or service on other sites.

Your use of any external website is governed by the terms of that website, including any authorisation, requirement or licence for use of the material on that website.

To the maximum extent permitted by law, St John WA excludes liability (including liability in negligence) for any direct, special, indirect, incidental, consequential, punitive, exemplary or other loss, cost, damage or expense arising out of, or in connection with, use or reliance on the Clinical Resources (including without limitation any interference with or damage to a user’s computer, device, software or data occurring in connection with such use).


Please read this cookie policy carefully before using Clinical Resources from St John WA.

The cookies used on this site are small and completely anonymous pieces of information and are stored on your computer or mobile device. The data that the cookies contain identify your user preferences (such as your preferred text size, scope / skill level preference and Colour Assist mode, among other user settings) so that they can be recalled the next time that you visit a page within Clinical Resources. These cookies are necessary to offer you the best and most efficient possible experience when accessing and navigating through our website and using its features. These cookies do not collect or send analytical information back to St John WA.

Clinical Resources does integrate with Google Analytics and any cookies associated with this service enable us (and third-party services) to collect aggregated data for statistical purposes on how our visitors use this website. These cookies do not contain personal information such as names and email addresses and are used to help us improve your user experience of the website.

If you want to restrict or block the cookies that are set by our website, you can do so through your browser setting. Alternatively, you can visit www.internetcookies.com, which contains comprehensive information on how to do this on a wide variety of browsers and devices. You will find general information about cookies and details on how to delete cookies from your device. If you have any questions about this policy or our use of cookies, please contact us.

St John Ambulance Western Australia Ltd © Copyright 2020, All Rights Reserved

Terms of Use | Privacy Policy | Copyright Statement & Disclaimer