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Hypoglycemia in emergency medical care

Hypoglycemia in emergency medical care

Disclaimer: This article is for information only and should Hypoglycwmia Hypoglycemia in emergency medical care used for the diagnosis im treatment of medical conditions. If you don't use medications known to cause hypoglycemia, your health care provider will want to know:. Explore careers. The World Health Organization WHO defines hypoglycaemia in children as levels below 2.

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Hypoglycemis signs and symptoms of hypoglycemia are divided into two groups based on energency mechanisms. Hypoglycemia symptoms include those xare by autonomic nervous system response, as well as direct neuroglycopenic symptoms. Neuroglycopenic signs and Hypoglyccemia include cognitive impairment, behavioral mesical, and psychomotor changes ranging up to potential seizure, coma, Hypiglycemia, ultimately, death typically due to cardiac arrest.

Drugs may interfere with these mechanisms. For example, beta-blockers e. This can increase the severity of hypoglycemia by blocking the compensatory effects of endogenous epinephrine in increasing BG levels and resulting in a delay in exogenous treatment. Hypoglycemia is part of the differential diagnosis for any patient found in a semiconscious or unconscious state.

Most hospitals have well-developed protocols to treat hypoglycemia. Hypoglycemia in hospitalized patients has been associated with increased mortality, which could be due to the more severe nature of illness in patients who tend to become hypoglycemic or could be related to the hypoglycemia itself.

Most patients were receiving basal insulin and most cases were nocturnal hypoglycemic events. Standardized hospital-wide, nurse-initiated hypoglycemia treatment protocols are preferred. Primary prevention consisting of identifying and mitigating risk factors and triggers for hypoglycemia is also recommended.

As discussed earlier, hypoglycemia encountered in the hospital is often iatrogenic, with a large number of cases related to drug therapy. It is important to assess the BG level of any patient with hypoglycemic signs and symptoms.

However, unavailability of testing equipment should not delay treatment if hypoglycemia is suspected. In the conscious patient, the most practical treatment is the oral administration of a rapid-acting carbohydrate TABLE 4.

If needed, additional Hgpoglycemia doses of carbohydrate may be administered to resolve symptoms and increase blood sugar above an established threshold e. Hypoglycemic type 2 diabetes patients taking alpha-glucosidase inhibitors who are treated with oral carbohydrates must receive monosaccharides e.

Glucagon, a counterregulatory pancreatic hormone, causes the breakdown and release of glycogen from the liver to increase BG concentrations. A glucagon kit for emergency treatment of hypoglycemia is recommended for any patient with a history of severe hypoglycemia or who is at risk for it.

The kit is particularly useful for patients in the community or in long-term care facilities where IV administration of dextrose is not feasible.

Close contacts of the patient e. Other formulations of glucagon premixed injectable solutions and nasal sprays are being developed to improve ease of administration in the community setting. Reversal of hypoglycemia relies on sufficient hepatic glycogen stores and other factors.

Patients normally respond within 15 minutes; IV glucose must be administered as soon as possible to any patient failing to respond to glucagon. IV dextrose is the best treatment for inpatients and for patients found by emergency medical services personnel. IV dextrose is available in different concentrations.

It is recommended to administer 10 to 25 g mL over 1 to 3 minutes. Rapid or excessive administration can induce hyperosmolar syndrome, and prolonged use especially when insulin levels are high can lead to hypokalemia.

Patients who are given dextrose and sodium chloride solutions are at risk for hypokalemia, fluid overload, and edema. Once recovered, regardless of the method used to increase serum glucose oral, IV, or liver glycogenolysis due to glucagonthe patient should continue to receive supplementation to prevent recurrence and reestablish glycogen stores as necessary.

If NPO, parenteral supplementation should continue to prevent hypoglycemia. If conscious and oral intake is possible, the patient should consume foods with longer-acting sources of energy complex carbohydrates, fats, proteins in order to prevent recurrence.

Pharmacists are well positioned to directly prevent, recognize, and treat hypoglycemia, and they can successfully develop institutional protocols and procedures and educate patients, caregivers, and other healthcare practitioners to achieve these goals.

Treatment of hypoglycemia depends on the severity and setting, and ranges from self-treatment with oral administration of 15 g of simple carbohydrates to outpatient use of glucagon kits and from oral intake to parenteral dextrose or glucagon administration at an institution.

Pharmacist involvement in the care of patients at risk for hypoglycemia and in education on prevention, recognition, and treatment of hypoglycemia for patients and their close family members and associates is critically important in helping reduce complications and improve outcomes.

Seaquist ER, Anderson J, Childs B, Cryer P, et al. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society.

J Clin Endocrinol Metab. International Hypoglycaemia Study Group. Glucose concentrations of less than 3. Diabetes Care. Minimizing hypoglycemia in diabetes.

Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. American Diabetes Association.

Introduction: Standards of Medical Care in Diabetes— Seaquist ER, Miller ME, Bonds DE, et al. The impact of frequent and unrecognized hypoglycemia on mortality in the ACCORD Study. Service FJ, Cryer PE, Vella A. Hypoglycemia in adults: clinical manifestations, definition, and causes.

Waltham, MA: UpToDate; Milligan PE, Bocox MC, Pratt E, et al. Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system. Am J Health Syst Pharm. Maynard G, Kulasa K, Ramos P, et al. Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management.

Endocr Pract. Hypoglycemia low blood glucose. Accessed September 12, Precose acarbose package insert. Wayne, NJ: Bayer HealthCare Pharmaceuticals Inc; March Glucagon: drug information. Accessed June 19, GlucaGen glucagon package insert. Plainsboro, NJ: Novo Nordisk, Inc; July Diabetes Canada Clinical Practice Guidelines Expert Committee.

Diabetes Canada clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes.

Lake Forest, IL: Hospira, Inc; October Mahadevan SV, Garmel GM, eds. An Introduction to Clinical Emergency Medicine. New York, NY: Cambridge University Press; ; Dextrose Injection package insert.

Deerfield, IL: Baxter Healthcare Corp; December Pharmacy Practice Affordable Medicines Biosimilars Compliance Compounding Drug Approvals. COVID Dermatology Diabetes Gastroenterology Hematology. mRNA Technology Neurology Oncology Ophthalmology Orthopedics.

: Hypoglycemia in emergency medical care

What is hypoglycaemia? D10 — How do they compare? Parsaik AK, Carter RE, Pattan V, Myers LA, Kumar H, Smith SA, Russi CS, Levine JA, Basu A, Kudva YC. Home EMCrit PulmCrit IBCC ODR About About EMCrit PulmCrit — The Full Story EMCrit FAQ Subscribe to the Newsletter Contact Join Why Should I Become a Member? Berry MG. The baby, a healthy newborn, was placed Thursday in a Safe Haven Baby Box.
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If left untreated, hypoglycemia can cause seizures and loss of consciousness. In severe cases, it can even be fatal. The symptoms of hypoglycemia can vary from person to person. Part of managing type 1 diabetes is learning to recognize your own signs and symptoms of hypoglycemia. You can treat the early symptoms of hypoglycemia by eating fast-acting carbohydrates.

Eat or drink about 15 grams of fast-acting carbs, such as:. After about 15 minutes, check your blood sugar level again. Repeat these steps until your blood sugar returns to the normal range.

Until your blood sugar returns to normal, avoid foods that contain fat, such as chocolate. These foods can take longer for your body to break down.

When your blood sugar returns to normal, try eating a snack or meal with carbohydrates and protein to help stabilize your blood sugar. For example, eat some cheese and crackers or half a sandwich. If you have a child with type 1 diabetes, ask their doctor how many grams of carbohydrates they should consume to treat hypoglycemia.

They might need fewer than 15 grams of carbs. If you develop severe hypoglycemia, you may be too confused or disoriented to eat or drink. In some cases, you may develop seizures or lose consciousness. This hormone signals your liver to release stored glucose, raising your blood sugar level.

To prepare for a potential emergency, you can buy a glucagon emergency kit or nasal powder. Let your family members, friends, or coworkers know where to find this medication — and teach them when and how to use it. A glucagon emergency kit contains a vial of powdered glucagon and a syringe filled with sterile liquid.

You must mix the powdered glucagon and liquid together before use. Then, you can inject the solution into the muscle of your upper arm, thigh, or butt. After a while, it thickens into a gel. As an alternative to injectable glucagon, the Food and Drug Administration FDA has recently approved glucagon nasal powder for treating hypoglycemia.

Glucagon nasal powder is ready to use without any mixing. You or someone else can spray it into one of your nostrils. Glucagon nasal powder can cause similar side effects as injectable glucagon. It may also cause respiratory tract irritation and watery or itchy eyes.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Egton Medical Information Systems Limited has used all reasonable care in compiling the information but make no warranty as to its accuracy.

Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions. This article is for Medical Professionals. Read COVID guidance from NICE.

In this article What is hypoglycaemia? Risk factors for hypoglycaemia Hypoglycaemia symptoms Hypoglycaemia treatment and management in adults Prolonged hypoglycaemic coma Treatment of hypoglycaemia in children Neonatal hypoglycaemia.

Hypoglycaemia Emergency Treatment and Management In this article What is hypoglycaemia? What is hypoglycaemia? A blood glucose of 4. Older literature suggests levels above 1. The World Health Organization WHO defines hypoglycaemia in children as levels below 2.

The patient must be admitted to hospital if hypoglycaemia is caused by an oral antidiabetic drug, because the hypoglycaemic effects of these drugs may persist for hours and ongoing glucose infusion or other therapies such as octreotide see under 'Hypoglycaemia which causes unconsciousness or fitting is an emergency', below may be required.

Children whose hypoglycaemia is caused by an oral antidiabetic drug should be transferred to hospital because the hypoglycaemic effects of these drugs may persist for hours. Are you protected against flu?

Join our weekly wellness digest from the best health experts in the business Enter your email Join now. Further reading and references.

Type 1 diabetes in adults: diagnosis and management ; NICE Guidelines August - last updated August Iqbal A, Heller S ; Managing hypoglycaemia. Diabetes - type 2 ; NICE CKS, October UK access only The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus 4th edition ; Joint British Diabetes Societies for inpatient care revised January Achoki R, Opiyo N, English M ; Mini-review: Management of hypoglycaemia in children aged months.

Related Information Hypoglycaemia Causes, Symptoms, and Treatment Miscellaneous Conditions - DVLA Guide Diabetes Mellitus - DVLA Guide Type 1 Diabetes Diazoxide Eudemine. My sugar is high in a morning.

Is there any advice. I'd appreciate your feed back. Join the discussion on the forums. Health Tools Feeling unwell? Assess your symptoms online with our free symptom checker. Start symptom checker. Notes on Hypoglycaemia close. Milligan PE, Bocox MC, Pratt E, et al. Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system.

Am J Health Syst Pharm. Maynard G, Kulasa K, Ramos P, et al. Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract. Hypoglycemia low blood glucose. Accessed September 12, Precose acarbose package insert.

Wayne, NJ: Bayer HealthCare Pharmaceuticals Inc; March Glucagon: drug information. Accessed June 19, GlucaGen glucagon package insert. Plainsboro, NJ: Novo Nordisk, Inc; July Diabetes Canada Clinical Practice Guidelines Expert Committee.

Diabetes Canada clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. Lake Forest, IL: Hospira, Inc; October Mahadevan SV, Garmel GM, eds. An Introduction to Clinical Emergency Medicine.

New York, NY: Cambridge University Press; ; Dextrose Injection package insert. Deerfield, IL: Baxter Healthcare Corp; December Pharmacy Practice Affordable Medicines Biosimilars Compliance Compounding Drug Approvals.

COVID Dermatology Diabetes Gastroenterology Hematology. mRNA Technology Neurology Oncology Ophthalmology Orthopedics. Featured Issue Featured Supplements.

COVID Resources. US Pharm. Causes In many cases, hypoglycemia is iatrogenic, often pharmacologically induced upon administration of insulin or other drugs that increase insulin secretion, particularly sulfonylureas and the shorter-acting glinides meglitinides.

To comment on this article, contact rdavidson uspharmacist. January In This Issue Digital Magazine Archives Subscription. Related CE. View More CE. Related Content. Advertising Contacts Editorial Staff Professional Organizations Submitting a Manuscript Media Kit.

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HbA 1c results were available for The vast majority Baseline patient characteristics at the time of their first encounter with EMS for the treatment of hypoglycemia. For patients who experienced multiple encounters during the study period, characteristics from the first encounter are included.

Patient characteristics at the time of the EMS encounter as a function of whether patients were or were not transported to the ED. In this analysis, patients may be included more than once if they experienced multiple EMS encounters for hypoglycemia.

Patients with type 1 diabetes comprised Patients with type 1 diabetes, when compared with patients with type 2 diabetes, were generally younger, more often non-Hispanic White, and more often lived in urban areas.

Mean HbA 1c was 8. The majority of patients who experienced a hypoglycemia-related EMS encounter were being treated with bolus insulin at the time of their event Among patients with type 2 diabetes, specifically, Nineteen percent of patients had an active glucagon prescription One-third were treated with oral glucose, while These data are presented separately for patients with type 1 and type 2 diabetes in Supplementary Tables 5 and 6.

Patients were transported to the ED in of 1, Rates of transport increased between Tables 1 and 2 compare patient and EMS encounter characteristics, respectively, between transported and nontransported patients.

Transported patients were, generally, older mean age Patients with type 1 diabetes were transported less frequently than patients with type 2 diabetes Nearly all examined comorbidities were more prevalent in transported than nontransported patients.

Fourteen percent of transported patients had a prior episode of severe hypoglycemia compared with Transported patients had greater prevalence of prior ED visits They were more often treated with glucose-lowering regimens that did not include bolus insulin, less frequently had active glucagon prescriptions In multivariate analysis Table 3 , the strongest predictors of transport to the ED were diabetes type OR 0.

type 2 diabetes , having had a prior ED visit OR 1. Patients who received glucagon from EMS were more likely to be transported OR 2. Among those with type 1 diabetes Supplementary Table 7 , the presence of comorbidities other than diabetes OR 2.

In contrast, among patients with type 2 diabetes Supplementary Table 8 , the odds of transport were associated with patient age 65—74 years: OR 3. Recurrent severe hypoglycemia was common, particularly among patients who were not transported to the ED Fig.

Within 3, 7, and 30 days of the index encounter, transported patients experienced recurrent severe hypoglycemia requiring medical attention 2.

Rates of recurrent EMS, ED, and hospitalization events among patients with type 1 and type 2 diabetes are detailed in Supplementary Tables 9— In multivariable analysis, patients who were transported had an OR of 0.

In subgroup analyses among patients with type 1 diabetes Supplementary Table 12 and type 2 diabetes Supplementary Table 13 , the odds of recurrent severe hypoglycemia among patients who were transported, as compared with those who were not transported, were 0.

Recurrent episodes of severe hypoglycemia requiring medical attention a composite of EMS, ED, and hospital utilization within 3, 7 and 30 days of the index hypoglycemia-related EMS encounter. Event rates are presented for the overall population as a function of whether patients were transported to the ED or left on scene A ; the overall population as a function of whether patients were transported to the ED and discharged without admission, were hospitalized, or were left on scene B ; patients with type 1 diabetes as a function of whether they were transported to the ED or left on scene C ; and patients with type 2 diabetes as a function of whether they were transported to the ED or left on scene D.

For patients who were hospitalized after the index hypoglycemic event, the at-risk period began on the day of discharge day 0. We further examined the rates of recurrent severe hypoglycemia composite of EMS, ED, and hospitalization events in subgroups of patient age Supplementary Table 14 and prior history of severe hypoglycemia Supplementary Table 15 , in which transported patients were also less likely to experience recurrent severe hypoglycemia.

Finally, we compared rates of recurrent severe hypoglycemia as a function of whether patients were left on scene, transported to the ED but discharged, or ultimately admitted to the hospital Fig.

Rates of recurrence decreased significantly with each higher level of care received. All-cause mortality was high among patients experiencing severe hypoglycemia treated by EMS, particularly among those who required transport Supplementary Table Within 30 days of the index EMS call, 58 transported 6.

Excluding patients who had died from analyses of recurrent severe hypoglycemia did not alter those results Supplementary Table When responding to a call for severe hypoglycemia, EMS providers face the decision of whether to transport patients to the ED, as this may provide for opportunities to engage patients, identify reasons for the hypoglycemic event, deliver education, and modify treatment regimens to reduce the likelihood of hypoglycemia recurrence.

However, ED visits are costly to the patient and the health care system and as such should be limited to situations in which higher levels of care are truly necessary and beneficial to the patient. There is substantial variability in the published transport rates of patients treated for severe hypoglycemia 21 , 23 , 24 , 26 — 31 , calling for the examination of transport practices and their implications on recurrent severe hypoglycemic events.

Our ability to leverage and link EMS and clinic EHR systems allowed us to identify patients with severe hypoglycemia requiring antihypoglycemic therapy rather than the primary impression of hypoglycemia, which has been shown to lack both sensitivity and specificity [ 23 ] , focus our analyses on patients with known diabetes, contextualize events with patient-level clinical information, and examine longitudinal severe hypoglycemia recurrence.

In our analysis of 1, EMS encounters for hypoglycemia between January and December made by 1, adults with diabetes, This transport rate is lower than observed in recent U. In both Minnesota and Wisconsin, there are no standard statewide patient care guidelines, such that transport decisions are made by the Medical Direction of each EMS agency.

When Rostykus et al. This practice may change with the Emergency Triage, Treat, and Transport payment model, which has been implemented in select ambulance agencies across the U.

over the past year, though it was not in place at Mayo Clinic Ambulance when this study was conducted. Factors associated with greater likelihood of transport to the ED were not surprising. Patients with type 1 diabetes were less likely to be transported than patients with type 2 diabetes, as were patients treated with medications known to cause hypoglycemia, while patients with prior history of ED utilization were more likely to be transported.

This decision is therefore likely influenced by multiple factors, including the perception of transport not adding value to their treatment or health as well as the desire to avoid the costs associated with EMS transport and an ED visit.

Younger patients, who are more often uninsured or underinsured than older patients, may therefore decline transport more often. When patients with type 1 and type 2 diabetes were examined separately, additional informative patterns emerged. This again suggests that otherwise healthy patients with type 1 diabetes, among whom severe hypoglycemia is likely to be the result of mismatches among administered insulin, carbohydrate intake, and physical activity, may not see the benefit of going to the ED once their hypoglycemia is adequately treated on scene.

Patients who call EMS at a higher glucose level and those who have underlying comorbidities may seek ED care for reasons beyond the correction of hypoglycemia, such as management of the factors that precipitated the hypoglycemic event in the first place.

In contrast, among patients with type 2 diabetes, the odds of transport were higher with increasing patient age, being unmarried, being treated with medications other than insulin, as well as higher glucose levels upon arrival. Hypoglycemia in older patients and patients with multiple comorbidities is more likely to be caused by factors other than glucose-lowering therapy.

They are more likely to experience infectious and ischemic events, be ill, or experience prolonged inadequate oral intake, all of which can contribute to hypoglycemia that is not readily reversed with one-time treatment and elicit concern among EMS providers, patients, and caregivers.

The higher rate of transport among single patients, who are less likely to have a caregiver available in the home, underscores the importance of caregiver support for ensuring patient safety if left on scene.

Nevertheless, non-White patients made up a higher proportion of the transported This may be driven by less access to diabetes care, greater reliance on the ED as the primary site of medical care, or lack of adequate diabetes self-management education to empower patients to modify their own treatment regimens or have a clinician to reach out to for guidance in the event of a severe hypoglycemic event.

Such lack of resources among racial and ethnic minority groups has been noted in prior research and underscores the pervasive impacts of structural racism in the health care system. EMS clinicians may also advise transport to patients they believe not have adequate follow-up or ability to self-manage, and the higher rate of transport among non-White patients may reflect this bias.

Rural patients also made up a higher proportion of the nontransported Patients with an active glucagon prescription were transported to the ED less often than patients without one However, in multivariate analysis, the availability of a glucagon prescription was not independently associated with reduced risk of ED transport.

Rates of glucagon prescribing were much higher in our population than in recently reported national studies of patients experiencing severe hypoglycemia 40 , 41 Prospective studies will be needed to examine the impact of glucagon availability on rates of severe hypoglycemic events requiring EMS, ED, and hospital-level care.

Importantly, transported patients were half as likely to experience recurrent severe hypoglycemia. The higher rates of recurrent hypoglycemia among nontransported patients were apparent in patients with both type 1 and type 2 diabetes, though the magnitude of effect was stronger in patients with type 2 than type 1 diabetes OR 0.

The ED encounter may provide an opportunity for treatment modification both directly, during the ED visit, and indirectly, because in our health system, primary care providers are automatically notified when their patients are seen in the ED, prompting them to follow up with their patients after such events occur.

Such treatment modification, whether change in the medication regimen, prescription of glucagon, or delivery of diabetes self-management education, is critical for the prevention of recurrent hypoglycemia. A systemic notification strategy is important because patients generally do not report their hypoglycemic event to their health care providers 42 , 43 , and providers do not consistently screen their at-risk patients for hypoglycemia Multiple studies 41 , 44 have demonstrated low rates of treatment modification after severe hypoglycemic events, which increases the likelihood of their recurrence.

Efforts are currently underway to examine, in detail, treatment modifications that may have occurred after the index hypoglycemic event among both transported and nontransported patients in order to elucidate what factors, exactly, were responsible for lower rates of hypoglycemia recurrence among transported patients.

While this investigation was outside the scope of our current work, our findings underscore the importance of patients informing their health care providers about their hypoglycemic events in a timely manner given the high rate of hypoglycemia recurrence even within 3 days of the initial event and clinicians intervening to prevent hypoglycemia recurrence.

Similarly, health care systems should develop systems to follow up with patients after all acute care utilization events, including EMS encounters if these can be identified by the health care system , ED visits, and hospitalizations.

Ambulance services rarely, if ever, have access to EHR systems of the sites where their patients receive medical care. This creates two important challenges. As a result, there is little opportunity for altering medication regimens or providing education focused on preventing another episode.

While this is one of the largest contemporary studies of severe hypoglycemia requiring EMS care that was further enriched by linking longitudinal EMS and clinic EHR data, it has important limitations.

Mayo Clinic Ambulance may not have been the first responder on scene e. We could not tell if patients resided in a skilled nursing facility or another congregate setting at the time or after the index hypoglycemic event.

We also could not examine the rates of hypoglycemic events that were treated by family or bystanders and did not culminate in an EMS, ED, or hospital encounter. While we were not able to capture ED visits and hospitalizations outside of Mayo Clinic or MCHS, because Mayo Clinic Ambulance is the sole EMS provider in the catchment area, the number of missed clinical encounters is likely very small.

Finally, this is not a population estimate, and findings may not generalize to other settings and populations. Nevertheless, our findings are representative of the upper Midwest, including both urban and rural settings. Nearly half of severe hypoglycemic events treated by Mayo Clinic Ambulance service resulted in transport to the ED.

Transport rates were highest among patients with type 2 diabetes. Among patients with type 1 diabetes, presence of comorbidities was the strongest predictor of transport to the ED. In contrast, among patients with type 2 diabetes, factors associated with transport included older age, being single i.

Recurrent severe hypoglyce-mic events were common in this population, particularly among patients who were not transported to the ED after their initial event. Severe Sepsis. Traumatic Brain Injury. Point-of-care POC glucose testing is readily available in most clinical settings, and offers an immediate diagnosis in most patients with suspected hypoglycemia.

POC glucose testing should be performed in all patients with suspected hypoglycemia or at risk for hypoglycemia, and should promptly follow completion of the primary survey. While generally reliable, POC glucose testing may provide inaccurate results in certain scenarios, including extremely elevated and extremely decreased serum glucose levels, and significantly delayed testing of obtained blood samples.

In these scenarios, testing should be repeated, ideally from venipuncture specimens and with formal laboratory assays e. basic metabolic panel [BMP] testing.

Additional testing should target potential precipitating causes for confirmed hypoglycemia, as well as conditions that may mimic symptoms of hypoglycemia in cases of diagnostic uncertainty.

When hypoglycemia is suspected to result from acute infection, reasonable additional testing may include:. In patients with underlying hepatic or endocrinologic dysfunction, additional testing may include:.

In otherwise healthy nondiabetic patients, in addition to the above-mentioned tests, also consider:. Given the exceedingly low likelihood of adverse events, glucose administration should not be delayed while awaiting diagnostic confirmation in patients with presentations suggestive of hypoglycemia..

Oral: Oral glucose is the preferred route of administration when it can be given safely in awake and alert patients without contraindication to oral medications. In adults, a total of g cal of carbohydrate should be given soda, juice, sandwich, snacks.

Supplementation with complex carbohydrates will allow for sustained normoglycemic levels. D50 pre-mixed ampules are readily available in many clinical environments and all emergency departments , and consequently represent a first-line intervention for hypoglycemia for many clinicians.

However, D50 may be associated with a greater risk of rebound hypoglycemia, hypertonic toxicity, and post-treatment hyperglycemia.

Monitor mental status and blood glucose measurements every min after glucose administration for hours, and then as needed for persistent hypoglycemia thereafter. Persistent hypoglycemia may require additional glucose boluses or continuous infusions of glucose. Consider giving parenteral thiamine at the time of glucose administration in patients at risk for thiamine deficiency to prevent Wernickes encephalopathy e.

starved state, chronic alcohol consumption. Glucagon: Intramuscular glucagon may be used when there is no IV access and oral glucose cannot be safely given. In adults, administer 1 mg IM.

In conditions with depleted glycogen stores elderly, advanced liver disease, starved state , glucagon may not be effective.

Octreotide: Intravenous octreotide may be useful in the setting of persistent hypoglycemia not responsive to other therapies e. sulfonylurea toxicity.

Glucose should be checked every hours after starting octreotide. Typically these patients will require several hours of close monitoring. Additional episodes of hypoglycemia need to be aggressively treated and only after ability to maintain normoglycemia should discharge be considered.

Discharge criteria for patients following a symptomatic episode of hypoglycemia:. Admission is often appropriate if any of the above-listed conditions are unmet. Despite oral refeeding and continued monitor for several hours, the patient continues to have episodes of moderate hypoglycemia.

The patient was admitted for observation due to her age and need for hour observation to ensure sustained serum normoglycemia for the duration of action of her Levemir insulin..

Upon admission, the patient stated that she lost her reading glasses earlier that evening. She was subsequently discharged the following day and scheduled an appointment with her optometrist the day of her discharge. Levemir has an onset of action of hours, has a peak action around hours, and lasts 24 hours.

Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ. American Diabetes Association. Introduction: Standards of Medical Care in Diabetes— Seaquist ER, Miller ME, Bonds DE, et al. The impact of frequent and unrecognized hypoglycemia on mortality in the ACCORD Study.

Service FJ, Cryer PE, Vella A. Hypoglycemia in adults: clinical manifestations, definition, and causes. Waltham, MA: UpToDate; Milligan PE, Bocox MC, Pratt E, et al. Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system.

Am J Health Syst Pharm. Maynard G, Kulasa K, Ramos P, et al. Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract. Hypoglycemia low blood glucose. Accessed September 12, Precose acarbose package insert.

Wayne, NJ: Bayer HealthCare Pharmaceuticals Inc; March Glucagon: drug information. Accessed June 19, GlucaGen glucagon package insert.

Plainsboro, NJ: Novo Nordisk, Inc; July Diabetes Canada Clinical Practice Guidelines Expert Committee. Diabetes Canada clinical practice guidelines for the prevention and management of diabetes in Canada.

Can J Diabetes. Lake Forest, IL: Hospira, Inc; October Mahadevan SV, Garmel GM, eds. An Introduction to Clinical Emergency Medicine. New York, NY: Cambridge University Press; ; Dextrose Injection package insert.

Deerfield, IL: Baxter Healthcare Corp; December Pharmacy Practice Affordable Medicines Biosimilars Compliance Compounding Drug Approvals. COVID Dermatology Diabetes Gastroenterology Hematology.

mRNA Technology Neurology Oncology Ophthalmology Orthopedics. Featured Issue Featured Supplements. COVID Resources. US Pharm. Causes In many cases, hypoglycemia is iatrogenic, often pharmacologically induced upon administration of insulin or other drugs that increase insulin secretion, particularly sulfonylureas and the shorter-acting glinides meglitinides.

Hypoglycemia in emergency medical care -

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Emergency Medicine Reports. et al. Threshold-based insulin-pump interruption for reduction of hypoglycemia. N Engl J Med. Grunberger G, Abelseth J, Bailey T, Bode B, Handelsman Y, et al. Consensus statement by the American association of clinical endocrinologists and American college of endocrinology insulin pump management task force.

Endocrine Practice. Kedia N. Treatment of severe diabetic hypoglycemia with glucagon: an underutilized therapeutic approach.

Diabetes Metab Syndr Obes. Share this: Email Tweet. Leave a Reply Cancel reply Your email address will not be published. emDOCs subscribes to the Free Open Access Meducation FOAMed initiative. Our goal is to inform the global EM community with timely and high yield content about what providers like YOU are seeing and doing everyday in your local ED.

Algorithm of the month Wheezing and Stridor. Popular Recent Comments. EMDOCS IN YOUR MAILBOX Enter your email address to receive notifications of new posts by email. Featured Articles. emDOCs Podcast — Episode practice updates. ABG Versus VBG in the Emergency Dep ECG Pointers: Recurrent and Refract emDOCs Podcast — Episode GLP Policy Playbook: Labor Actions and In subgroup analyses among patients with type 1 diabetes Supplementary Table 12 and type 2 diabetes Supplementary Table 13 , the odds of recurrent severe hypoglycemia among patients who were transported, as compared with those who were not transported, were 0.

Recurrent episodes of severe hypoglycemia requiring medical attention a composite of EMS, ED, and hospital utilization within 3, 7 and 30 days of the index hypoglycemia-related EMS encounter.

Event rates are presented for the overall population as a function of whether patients were transported to the ED or left on scene A ; the overall population as a function of whether patients were transported to the ED and discharged without admission, were hospitalized, or were left on scene B ; patients with type 1 diabetes as a function of whether they were transported to the ED or left on scene C ; and patients with type 2 diabetes as a function of whether they were transported to the ED or left on scene D.

For patients who were hospitalized after the index hypoglycemic event, the at-risk period began on the day of discharge day 0. We further examined the rates of recurrent severe hypoglycemia composite of EMS, ED, and hospitalization events in subgroups of patient age Supplementary Table 14 and prior history of severe hypoglycemia Supplementary Table 15 , in which transported patients were also less likely to experience recurrent severe hypoglycemia.

Finally, we compared rates of recurrent severe hypoglycemia as a function of whether patients were left on scene, transported to the ED but discharged, or ultimately admitted to the hospital Fig. Rates of recurrence decreased significantly with each higher level of care received.

All-cause mortality was high among patients experiencing severe hypoglycemia treated by EMS, particularly among those who required transport Supplementary Table Within 30 days of the index EMS call, 58 transported 6.

Excluding patients who had died from analyses of recurrent severe hypoglycemia did not alter those results Supplementary Table When responding to a call for severe hypoglycemia, EMS providers face the decision of whether to transport patients to the ED, as this may provide for opportunities to engage patients, identify reasons for the hypoglycemic event, deliver education, and modify treatment regimens to reduce the likelihood of hypoglycemia recurrence.

However, ED visits are costly to the patient and the health care system and as such should be limited to situations in which higher levels of care are truly necessary and beneficial to the patient. There is substantial variability in the published transport rates of patients treated for severe hypoglycemia 21 , 23 , 24 , 26 — 31 , calling for the examination of transport practices and their implications on recurrent severe hypoglycemic events.

Our ability to leverage and link EMS and clinic EHR systems allowed us to identify patients with severe hypoglycemia requiring antihypoglycemic therapy rather than the primary impression of hypoglycemia, which has been shown to lack both sensitivity and specificity [ 23 ] , focus our analyses on patients with known diabetes, contextualize events with patient-level clinical information, and examine longitudinal severe hypoglycemia recurrence.

In our analysis of 1, EMS encounters for hypoglycemia between January and December made by 1, adults with diabetes, This transport rate is lower than observed in recent U. In both Minnesota and Wisconsin, there are no standard statewide patient care guidelines, such that transport decisions are made by the Medical Direction of each EMS agency.

When Rostykus et al. This practice may change with the Emergency Triage, Treat, and Transport payment model, which has been implemented in select ambulance agencies across the U. over the past year, though it was not in place at Mayo Clinic Ambulance when this study was conducted.

Factors associated with greater likelihood of transport to the ED were not surprising. Patients with type 1 diabetes were less likely to be transported than patients with type 2 diabetes, as were patients treated with medications known to cause hypoglycemia, while patients with prior history of ED utilization were more likely to be transported.

This decision is therefore likely influenced by multiple factors, including the perception of transport not adding value to their treatment or health as well as the desire to avoid the costs associated with EMS transport and an ED visit.

Younger patients, who are more often uninsured or underinsured than older patients, may therefore decline transport more often. When patients with type 1 and type 2 diabetes were examined separately, additional informative patterns emerged. This again suggests that otherwise healthy patients with type 1 diabetes, among whom severe hypoglycemia is likely to be the result of mismatches among administered insulin, carbohydrate intake, and physical activity, may not see the benefit of going to the ED once their hypoglycemia is adequately treated on scene.

Patients who call EMS at a higher glucose level and those who have underlying comorbidities may seek ED care for reasons beyond the correction of hypoglycemia, such as management of the factors that precipitated the hypoglycemic event in the first place.

In contrast, among patients with type 2 diabetes, the odds of transport were higher with increasing patient age, being unmarried, being treated with medications other than insulin, as well as higher glucose levels upon arrival. Hypoglycemia in older patients and patients with multiple comorbidities is more likely to be caused by factors other than glucose-lowering therapy.

They are more likely to experience infectious and ischemic events, be ill, or experience prolonged inadequate oral intake, all of which can contribute to hypoglycemia that is not readily reversed with one-time treatment and elicit concern among EMS providers, patients, and caregivers. The higher rate of transport among single patients, who are less likely to have a caregiver available in the home, underscores the importance of caregiver support for ensuring patient safety if left on scene.

Nevertheless, non-White patients made up a higher proportion of the transported This may be driven by less access to diabetes care, greater reliance on the ED as the primary site of medical care, or lack of adequate diabetes self-management education to empower patients to modify their own treatment regimens or have a clinician to reach out to for guidance in the event of a severe hypoglycemic event.

Such lack of resources among racial and ethnic minority groups has been noted in prior research and underscores the pervasive impacts of structural racism in the health care system.

EMS clinicians may also advise transport to patients they believe not have adequate follow-up or ability to self-manage, and the higher rate of transport among non-White patients may reflect this bias.

Rural patients also made up a higher proportion of the nontransported Patients with an active glucagon prescription were transported to the ED less often than patients without one However, in multivariate analysis, the availability of a glucagon prescription was not independently associated with reduced risk of ED transport.

Rates of glucagon prescribing were much higher in our population than in recently reported national studies of patients experiencing severe hypoglycemia 40 , 41 Prospective studies will be needed to examine the impact of glucagon availability on rates of severe hypoglycemic events requiring EMS, ED, and hospital-level care.

Importantly, transported patients were half as likely to experience recurrent severe hypoglycemia. The higher rates of recurrent hypoglycemia among nontransported patients were apparent in patients with both type 1 and type 2 diabetes, though the magnitude of effect was stronger in patients with type 2 than type 1 diabetes OR 0.

The ED encounter may provide an opportunity for treatment modification both directly, during the ED visit, and indirectly, because in our health system, primary care providers are automatically notified when their patients are seen in the ED, prompting them to follow up with their patients after such events occur.

Such treatment modification, whether change in the medication regimen, prescription of glucagon, or delivery of diabetes self-management education, is critical for the prevention of recurrent hypoglycemia.

A systemic notification strategy is important because patients generally do not report their hypoglycemic event to their health care providers 42 , 43 , and providers do not consistently screen their at-risk patients for hypoglycemia Multiple studies 41 , 44 have demonstrated low rates of treatment modification after severe hypoglycemic events, which increases the likelihood of their recurrence.

Efforts are currently underway to examine, in detail, treatment modifications that may have occurred after the index hypoglycemic event among both transported and nontransported patients in order to elucidate what factors, exactly, were responsible for lower rates of hypoglycemia recurrence among transported patients.

While this investigation was outside the scope of our current work, our findings underscore the importance of patients informing their health care providers about their hypoglycemic events in a timely manner given the high rate of hypoglycemia recurrence even within 3 days of the initial event and clinicians intervening to prevent hypoglycemia recurrence.

Similarly, health care systems should develop systems to follow up with patients after all acute care utilization events, including EMS encounters if these can be identified by the health care system , ED visits, and hospitalizations.

Ambulance services rarely, if ever, have access to EHR systems of the sites where their patients receive medical care. This creates two important challenges. As a result, there is little opportunity for altering medication regimens or providing education focused on preventing another episode.

While this is one of the largest contemporary studies of severe hypoglycemia requiring EMS care that was further enriched by linking longitudinal EMS and clinic EHR data, it has important limitations. Mayo Clinic Ambulance may not have been the first responder on scene e.

We could not tell if patients resided in a skilled nursing facility or another congregate setting at the time or after the index hypoglycemic event.

We also could not examine the rates of hypoglycemic events that were treated by family or bystanders and did not culminate in an EMS, ED, or hospital encounter. While we were not able to capture ED visits and hospitalizations outside of Mayo Clinic or MCHS, because Mayo Clinic Ambulance is the sole EMS provider in the catchment area, the number of missed clinical encounters is likely very small.

Finally, this is not a population estimate, and findings may not generalize to other settings and populations. Nevertheless, our findings are representative of the upper Midwest, including both urban and rural settings.

Nearly half of severe hypoglycemic events treated by Mayo Clinic Ambulance service resulted in transport to the ED. Transport rates were highest among patients with type 2 diabetes.

Among patients with type 1 diabetes, presence of comorbidities was the strongest predictor of transport to the ED.

In contrast, among patients with type 2 diabetes, factors associated with transport included older age, being single i. Recurrent severe hypoglyce-mic events were common in this population, particularly among patients who were not transported to the ED after their initial event.

ED transport nearly halved the likelihood of severe hypoglycemia, underscoring the importance of clinical evaluation in the aftermath of severe hypoglycemia to provide an opportunity for timely patient education and treatment modification. This article is featured in a podcast available at diabetesjournals.

The authors thank M. Carson Rogerson IV Mayo Clinic Ambulance for assistance with accessing Mayo Clinic Ambulance data and Theo Herrin formerly of Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery for assistance accessing Mayo Clinic data.

and the Mayo Clinic K2R Research Award. Study contents are the sole responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Duality of Interest. In the last 36 months, R. has consulted with Emmi on the development of patient education materials related to prediabetes and diabetes.

No other potential conflicts of interest relevant to this article were reported. Author Contributions. and R. designed the study, interpreted the data, and wrote the manuscript. analyzed the data and reviewed and edited the manuscript. assisted with data analyses and reviewed and edited the manuscript.

are the guarantors of this work and, as such, had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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User Tools Dropdown. Sign In. Skip Nav Destination Close navigation menu Article navigation. Volume 45, Issue 8. Previous Article Next Article. Research Design and Methods. Article Information. Article Navigation. Management and Outcomes of Severe Hypoglycemia Treated by Emergency Medical Services in the U.

Coupling microcirculation to hemodynamics. Cur Opin Crit Care. Inoue S, Egi M, Kotani J, Morita K. Accuracy Of blood-glucose measurements using glucose meters and arterial blood gas analyzers in critically ill adult patients: systematic review.

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Bondanelli M, Ambrosio MR, Zatelli MC, De Marinis L, Ubert ET. Hypopituarism after traumatic brain injury. Eur J Endocrinolol. Arinzon Z, Fidelman Z, Berner YN, Adunsky A.

Infection-related hypoglycemia in institutionalized demented patients. A comparative study of diabetic and nondiabetic patients. Arch Gerontol Geriatr. MacMahon EM. Metamphetamine-induced insulin release. Faskowitz AJ, Kramskiy VN, Pasternak GW.

Methadone-induced hypoglycemia. Cell Mol Neurobiol. Article CAS PubMed PubMed Central Google Scholar. Sakata T, Terada K, Arase K, Fujimoto K, Oomura Y, Okukado N, et al.

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Int J Cardiol. Khoury M, Yousuf F, Martin V, Cohen R. A cause for unreliable finger-stick glucose measurements. Berry MG. Tobacco hypoglycemia. Ann Intern Med. Download references. Department of Emergency Medicine and Services, Päijät-Häme Central Hospital, Keskussairaalankatu 7, , Lahti, Finland.

Department of Emergency Medicine, Helsinki University and Helsinki University Hospital, Lahti, Finland. You can also search for this author in PubMed Google Scholar. HV was responsible of the acquisition of the data. HV and JN were involved in the conception and design of the data.

HV was responsible of the analyses and interpretation of the data. HV, JN and MK revised the manuscript and approved the final version. All authors are accountable for the entirety of the manuscript. All authors read and approved the final manuscript.

Correspondence to Hanna Vihonen. The Helsinki University Hospital approved the study plan. No Ethics committee approval was required. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Scand J Trauma Resusc Emerg Med 26 , 12 Download citation. Received : 28 August Accepted : 15 January Published : 01 February Anyone you share the following link with will be able to read this content:.

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Download PDF. Original research Open access Published: 01 February Hypoglycaemia without diabetes encountered by emergency medical services: a retrospective cohort study Hanna Vihonen ORCID: orcid.

Abstract Background The current study investigates the incidence, aetiology, and outcome of hypoglycaemia of patients without diabetes in the EMS. Methods The study was a retrospective cohort study that utilized electronic EMS patient record system population of one million.

Discussion The most common possible hypoglycaemia related aetiological causes encountered in the EMS, alcohol abuse, hypothermia, and malnutrition, although frequent are often relatively benign conditions.

Conclusions Hypoglycaemia without diabetes is commonly observed among the hypoglycaemic EMS cases. Background Plasma glucose disturbances are commonly observed in the emergency medical services EMS setting.

Methods Study design We conducted a retrospective cohort study based on the electronic EMS records and hospital patient records combined with national registry data on cause of death and reimbursement entitlement status of medicine. Population We included all patients in the Helsinki University Hospital area encountered by EMS and with measured hypoglycaemia during the years to Study setting and data Helsinki University Hospital has the responsibility to organize and supervise EMS for about one million inhabitants in the Helsinki metropolitan area.

Data analysis Electronic EMS records were studied for chronic medical conditions for comparison of diabetics and non-diabetics. Inclusion and exclusion of study patients. Full size image. Table 1 Demographics, vital signs, previous comorbidities, transportation, and overall mortality rate of patient cases with diabetes and without diabetes Full size table.

Discussion Our study found that hypoglycaemic cases without diabetes was common among hypoglycaemic EMS cases. Conclusion We conclude that hypoglycaemic EMS cases without diabetes is frequently observed among hypoglycaemic EMS cases. Abbreviations A: highest priority dispatch code ADA: American diabetes association B: second highest priority dispatch code C: second lowest dispatch code D: lowest dispatch code EMA: European medicines agency EMS: emergency medical services GCS: Glasgow coma scale HIV: human immunosuppressive virus OHCA: out of hospital cardiac arrest.

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Medicxl Journal of Cwre Medicine volume Hypoglycemia in emergency medical care Sports nutrition for agility and speed in team sports, Article number: 28 Cite this article. Metrics Mdeical. In-hospital observation is typically recommended for Hypoglyceemia who present emegency the Enhance brain function department with symptomatic hypoglycemia who are taking oral diabetes medications or long acting insulin. Individuals considered to be at low risk of further hypoglycemic episodes by treating providers are however on occasion discharged to home when a low suspicion of recurrence and close observation is available. We describe the frequency of hypoglycemia recurrence requiring further emergency department evaluation who have been recently discharged from the emergency department and are taking oral diabetes medications or long-acting insulin. back to contents. Below is a general High-fat foods for carr hypoglycemia Hypoglycemiq threatened brain Hypoglycemia in emergency medical care. Glucose should be monitored Emergnecy throughout at least q1hr, or more frequently. Treatments should be titrated to achieve a safe glucose level e. Pushing the glucose too high can be counterproductive, as this can stimulate endogenous insulin release leading to rebound hypoglycemia. Continue working through the algorithm until the patient's glucose is stabilized.

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